自我健康状况监测表
Personal Health Monitoring Form
姓名/Name： 护照号/Passport No.：
|
7 天 7 days |
日 期 Date |
额头 腋窝 温度 Forehead Underarm temperature | 是否与核酸阳 性人员有过近 距离接触 Have you been in close contact with anyone who has been tested positive for nucleic acid? | 是否有发热、乏 力、呼吸道不适 等疑似症状 Do you have any suspected symptoms of infection such as fever,fatigue or respiratory discomfort? |
是否服用退 烧药、感冒药 等药物 Have you taken any medicine for fever or cold, etc.? |
| 第 1 天 Day 1 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 2 天 Day 2 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 3 天 Day 3 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 4 天 Day 4 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 5 天 Day 5 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 6 天 Day 6 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ | |
| 第 7 天 Day 7 | ℃ | 是Yes□ 否No□ | 是Yes□ 否No□ | 是Yes□ 否No□ |
本人保证以上填写信息真实、准确、完整，并知悉我将承担瞒报的法律后果。
I hereby declare that the information provided above is true, accurate and complete, and I am aware of the legal consequences in the case of partial or false disclosures.
本人签名/Signature： 联系电话/Tel. Number：
