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自我健康状况监测表Persona IHealth Moni tori ngForm姓名Name护照号Passport No.是否有发热、乏是否与核酸阴性力、呼吸道不适人员有过近距离等疑权症状Do接触Have you是否服用退烧you haveany beenin close药、感冒药等参日期体温7天suspected contactwith物symptoms ofBody anyonewho hasHave youtaken7Days Dateinfection suchTemperature beentested anymedicine foras fever,fatigue positivefor feveror cold,or respiratorynucleic acidetc.discomfort第1天Day1第2天Day2第3天Day3第4天Day4第5天Day5第6天Day6第7天Day7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 herebydeclare thatthe informationprovided aboveis true,accurate andcomplete,and Iam awareof thelegal consequencesin thecase ofpartial orfalse disclosures.本人签名Signature联系电话Telephone Number。