自我健康状况监测表.docx

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1、自我健康状况监测表Persona1Hea1thMonitoringForm姓名Name：,护照号PassportNo.：14天14Days日期Date体温BodyTemperature是否与核酸阳性人员有过近距离接触Haveyoubeeninc1osecontactwithanyonewhohasbeentestedpositivefornuc1eicacid?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Ha

2、veyoutakenanymedicineforfeverorco1d,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口是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口是Yes否No第7天Day7是Yes否No是Yes口否N。口是Yes否No第天Day8是Yes否No是Yes否No口是Yes否No第9天Day9是Yes否No是Yes否NoO是Yes否No第1

3、0天Day10是Yes否No是Yes否No是Yes否No第11天Day11是Yes否No是Yes否No是Yes否No第12天Day12是Yes否No是Yes否No口是Yes否No第13天Day14是Yes否No是Yes口否N0口是Yes否No第14天Day14是Yes否No是Yes否No是Yes否No口本人保证以上填写信息真实、准确、完整，井知悉我将承担瞒报的法律后果。Iherebydec1arethattheinformationprovidedaboveistrue,accurateandcomp1ete,andIamawareofthe1ega1consequencesinthecaseofpartia1orfa1sedisc1osures.本人签名Signature：联系电话Te1ephoneNumber：