文藻外語大學108學年教職員工健檢防疫調查表(含健康旅遊史)Survey for COVID-19 (for faculty and staff physical examination)

因應防疫需求，於活動開始前2周需調查參與人員出國史及健康資訊，請填寫以下表單，謝謝!
校內健檢日期為109年5月6日星期三上午7:30-11:00
地點: 文園1樓川堂
若您當天無法參與，請於5/16(六)前至聖功醫院3樓健檢中心完成健檢，預約電話07-2255263(醫院健檢時間為周一~六上午8:30~11:30)。
To prevent COVID-19, please fill in this form for risk assessment, thank you.
The physical examination date : 5/6 (Wed) 7:30-11:00
Location: 1F of Wenyuan
If you can not attend the physical on 5/6, please have the examination before 5/16(Sat) at the Health Examination Center St.Joseph Hospital. Reservation:07-2255263 (Office Hours : 8:30-11:30 Mon.-Sat.)

姓名Name *

職編Staff ID *

最近一個月是否出現下述症狀? Has the following symptoms occurred within 30 days? *

否 None.

發燒(>=38℃) Fever

咳嗽 Cough

喉嚨痛 Sore throat

呼吸道窘迫症狀(呼吸急促、呼吸困難)Symptoms of respiratory distress (shortness of breath, difficulty breathing)

流鼻水 Runny nose

肌肉酸痛Muscle ache

腹瀉 Diarrhea

味覺喪失 Lose sense of Taste

嗅覺喪失 Lose sense of Smell

Other:

Required

如有上述症狀，其起始日為?(若無不用填答) When did the above symptom appear?( Skip if choose "none")

YYYY

過去一個月或未來一個月是否出國(含轉機)? Did you go abroad(including transfers) in the past or the next month? *

否No

是Yes

如上題為 "是"，旅遊/接觸史(含轉機)地點:(若為 "否" 則不須填答) Location of above question ( Skip if choose "none")

您身體是否有這些症狀? Do you have the following health issues? *

否 None

慢性肺病 Chronic lung disease

重大疾病 Major diseases

Required

若上題為”是” 請註明疾病名稱。 What’s the diagnosis of above question?

您或與您同住的家屬或親友是否曾與感染嚴重特傳染性肺炎(武漢肺炎)病患有接觸?Have you or your family or friends who lived with you ever contact with patient of COVID-19? *

否 None

是Yes

上題若為 "是"，接觸者與您的關係為:(若為 "否" 則不須填答)What's the relationship between you and the contact? (Skip if choose None.)

上上題若為 "是"，接觸日期為:(若為 "否" 則不須填答)?Date of contact? (Skip if choose None.)

YYYY

5/6(三)上午，您是否會參與校內健檢?Will you attend the examination on 5/6 (Wed)? *

是 Yes.

否，會在5/16(六)前到聖功醫院檢查 No, I will go to St.Joseph Hospital before 5/16(Sat).

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