自我健康状况监测表

自我健康状况监测PersonalHealthMonitoringForm姓名Name：_____________________，护照号PassportNo.:_________________7天7Days日期Date体温BodyTemperature是否与核酸阳性人员有过近距离接触Haveyoubeeninclosecontactwithanyonewhohasbeentestedpositivefornucleicacid?是否有发热、乏力、呼吸道不适等疑似症状Doyouhaveanysuspectedsymptomsofinfectionsuchasfever,fatigueorrespiratorydiscomfort?是否服用退烧药、感冒药等药物Haveyoutakenanymedicineforfeverorcold,etc.?第1天Day1是Yes£否No£是Yes£否No£是Yes£否No£第2天Day2是Yes£否No£是Yes£否No£是Yes£否No£第3天Day3是Yes£否No£是Yes£否No£是Yes£否No£第4天Day4是Yes£否No£是Yes£否No£是Yes£否No£第5天Day5是Yes£否No£是Yes£否No£是Yes£否No£第6天Day6是Yes£否No£是Yes£否No£是Yes£否No£第7天Day7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。Iherebydeclarethattheinformationprovidedaboveistrue,accurateandcomplete,andIamawareofthelegalconsequencesinthecaseofpartialorfalsedisclosures.本人签名Signature：________联系电话TelephoneNumber:________