文本内容:
刍我健康状况监测表PersonalHealthMonitoringForm生名Name护口1号PassportNo.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IherebydeclarethattheinformationprovidedaboveistrueaccurateandcompleteandIamawareofthelegalconsequencesinthecaseofpartialorfalsedisclosures.本人签名Signature联系电话TelephoneNumber14天14Days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Doyouhaveanysuspectedsymptomsofinfectionsuchasfeverfatigueorrespiratorydiscomfort是否服用退烧药、感冒药等药物Haveyoutakenanymedicineforfeverorcoldetc.天11ay第D是Yes口否No□是Yes口否No口是YesD否No□第2天Day2是Yes口否No□是Yes口否No口是YesD否No□第3天Day3是Yes口否No□是Yes口否No口是YesD否No□第4天Day4是Yes口否No□是Yes口否No口是YesD否No□第5天Day5是YesD否No□是Yes口否No口是YesD否No□第6天Day6是Yes口否No□是YesD否NoD是YesD否No□第7天Day7是Yes口否No□是Yes口否No口是YesD否No□第8天Day8是YesD否No□是Yes口否No口是YesD否No□第9天Day9是Yes口否No□是Yes口否No口是YesD否No□第10天Day10是Yes口否No□是Yes口否No口是YesD否No□第11天Day11是YesD否No□是Yes口否No口是YesD否No□第12天Day12是Yes口否No□是Yes口否No口是Yes口否No□第13天Day14是Yes口否No□是Yes口否No口是Yes口否No□第14天Day14是Yes口否No□是Yes口否No口是YesD否No□。