Health Declaration Form  
Patients and visitors to Gleneagles Kota Kinabalu are reminded that providing false information is an offence under the Prevention and Control of Infectious Diseases Act 1988 (Act 342). The Hospital will be obliged to report such false information.

Full Name
Mobile Number
In the last 14 days, have you:
- Been exhibiting any COVID-19 symptoms?
a. Fever/chills
b. Sorethroat/cough/runny nose
c. Headache/body ache
d. Difficulty in breathing
e. Loss of smell /taste
f. Vomiting /Diarrhea
- Epidemiological risk factors:
Have you visited a foreign country, red zone area, attended an event related to COVID-19 outbreak,
come in contact / travelled / worked in close proximity / shared a classroom environment with a positive COVID-19 person?
  Yes   No
I hereby acknowledge that the information given in the form is correct and accurate.
I agree to the Privacy policy
My Body Temperature at Hospital entrance
Copyright © 2020 Gleneagles Kota Kinabalu. All Rights Reserved