Religious Pilgrimage Health Declaration Form
Personal Information
Full Name
Date of Birth
Passport/ID Number
Nationality
Contact Number
Address
Health Information
Existing Medical Conditions
Current Medications
Allergies
Recent Health Status
Fever
Cough
Sore Throat
Difficulty Breathing
None of the above
Have you been in contact with a confirmed infectious disease case in the past 14 days?
Yes
No
Vaccination Status
Fully Vaccinated
Partially Vaccinated
Not Vaccinated
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Signature
Date