LCP

Form No. 06-016

Jan. 2020

LUNG CENTER OF THE PHILIPPINES

Quezon Avenue, Quezon City

HOME QUARANTINE ADVICE FORM

NAME OF PATIENT (Surname, First Name Middle Name) AGE GENDER



1. You should stay under HOME QUARANTINE until ____/____/______.
2. You should have the following for your personal use at home:
Thermometer
Supply of masks
Alcohol-based hand sanitizer
3. While under HOME QUARANTINE you should:
Limit your movement only within the confines of one area (room, dormitory room, etc).
Sleep in a separate room away from other household members during the entire period of
quarantine.
Get your oral temperature at least twice a day (once in the morning and once in the
afternoon). Disinfect the thermometer with 70% isoprophyl alcohol.
Arrange to go on leave from work or school during the quarantine period.
Do not go to public places such as malls, markets, movie houses, swimming pools, places
of worship, parties and fiestas.
Minimize contact with other household members. If close contact cannot be avoided,
wear a mask.
Do not entertain visitors while under isolation and do not answer the door.
Cover nose and mouth with a facial tissue when coughing or sneezing.
Immediately after contact with body fluids (respiratory secretions, urine, and feces) wash
hands with soap and water or use an alcohol-based hand sanitizer.
Household waste soiled with body fluids, including facial tissues and masks may be
discarded as regular waste.
Environmental surfaces soiled with body fluids should be cleaned with disinfectants (i.e.
sodium hypochlorite or bleach).
Monitor your health status daily and watch out for fever, cough, sore throat, headache,
diarrhea, muscle pain, body weakness, rash, loss of appetite, and confusion.
Anticipate daily calls from DOH or local government unit personnel who will check on your
health status.


IF YOU DEVELOP ANY SYMPTOMS, PROMPTLY CONTACT THE SENIOR HOUSE OFFICER (SHO)

OF THE LUNG CENTER OF THE PHILIPPINES AT 8924-6101 OR PROCEED BACK TO THE LCP STU AREA.



Form explained by: ____________________________________ Date: _________________
(Signature over Printed Name)



Form received by: ____________________________________ Date: _________________
(Signature over Printed Name)

Accomplish this form in duplicate: Original copy to patient; Duplicate copy to patient’s record.