填表日期Fill in the date: 2025.06.02
看診日期Date of visit:
姓名Name(必填Required):
手機Phone(必填Required):
同行人數Number of companions: 1 2 3 4 5 6

一、最近14日內旅遊史?
Travel history in the last 14 days?

無 No

自身曾至國外旅遊 I have traveled abroad 前往的國家 country to visit:

二、您近一個月內群聚史?
Have you been in large crowds (in clusters) in the past month?
無 No
同住家人染疫隔離
Family members are quarantined
居家隔離
Home isolation
自主健康管理(到期日: 月/日)
Self-directed health management due date
家人也有發燒或呼吸道症狀
Family members also have fever or respiratory symptoms
朋友也有發燒或呼吸道症狀
Friends also have fever or respiratory symptoms
同事也有發燒或呼吸道症
Co-workers also have fever or respiratory symptoms

※備註： 如有相關群聚史 7 日後再 來院服務
※Note: If there is a history of related gatherings, you will come to the hospital for service after 7 days

三、最近 14 日內是否有下列症狀
Have you had any of the following symptoms in the last 14 days
無 No
發燒 Fever
咳嗽 Cough
喉嚨痛 Sore throat
流鼻水 Runny nose
腹瀉 Diarrhea
味覺或嗅覺異常 Abnormal sense of taste or smell
呼吸急促 Shortness of breath
倦怠 Burnout
其他 Other

※備註： 最近 14 日內曾有疑似感染 症狀暫勿來院服務隱匿傳染病相關訊息可能觸犯【傳染病防治 法】，最高可處十五萬元罰緩。
Concealing information related to infectious diseases may violate the [Infectious Disease Prevention and Control Law], and a maximum fine of 150,000 yuan may be imposed.