健康申報表 | Well Being

健康申報表 Health Declaration Form

姓名 Name: *

性別 Sex: *

聯絡電話 Contact Phone No. : *

如有以下任何症狀, 請加✓ if you have any of the following Symptoms, please put a ✓:

過去14天有外遊嗎? Have you been traveling for the past 14 days ? *

你曾到哪個國家? Which country?

過去14天內,曾否與疑似或證實感染新型冠狀病毒的人接觸? For the past 14 days, have you been in contact with a person who is suspected, or confirmed to have novel coronavirus? *

日期 Date: *

簽名 Signature : *