MASTERLIST FOR COVID-19 ELECTRONIC IMMUNIZATION REGISTRY

ADDRESS
CATEGORY CIVIL STATUS EMPLOYED

01-HEALTH CARE WORKER 01-SINGLE 01-GOVERNMENT

02-SENIOR CITIZEN 02-MARRIED 02-PRIVATE

PHILHEALTH ID
03-INDIGENT
ID NO LAST NAME FIRST NAME MIDDLE NAME SUFFIX CONTACT NO. SEX BIRTHDAY 03-WIDOW 03-SELF EMPLOYED
NO. ZONE BARANGAY
04-UNIFORMED PERSONNEL 04-SEPARATED/ANNULED 04-PRIVATE PRACTIONER

05-ESSENTIAL WORKER 05-LIVING WITH PARTNER 05-OTHER

06-OTHER
 PREGNANCY WITH WITH CO- WITH COVID COVID
IF YES CO-MORBIDITIES IF YES CONSENT
STATUS ALLERGY MORBIDITIES HISTORY CLASSIFICATION

01-PREGNANT 01-YES 01-DRUG 01-YES 01-HYPERTENSION 01-YES 01-ASYMPTOMATIC ARE YOU WILLING TO BE
VACCINATED?
DATE OF FIRST POSITIVE RESULT
02-NOT PREGNANT 02-NO 02-FOOD 02-NO 02-HEART DISEASE 02-NO SPECIMEN COLLECTION (MM/YYYY) 02-MILD

EMPLOYER EMPLOYER
PROFESSION EMPLOYER 03-INSECT 03-KIDNEY DISEASE 03-MODERATE 01-YES
ADDRESS CONTACT #
04-LATEX 04-DIABETES 04-SEVERE 02-NO

05-MOLD 05-BRONCHIAL ASTHMA 05-CRITICAL 03-UNKNOWN

06-PET 06-IMMUNODEFICIENCY STATUS

07-POLLEN 07-CANCER

08-VACCINE 08-OTHERS