健康申報表格 Travel and Health Declaration Form
有鑒於2019年新型冠狀病毒肺炎的最新發展,閣下在接受輔導服務前一個工作天,必須填寫以下健康聲明和旅遊申報,任何已從海外返回或與從海外(包括澳門和中國大陸)返回的人同住(包括航空公司機組人員及參與「回港易」計劃的香港居民),必須在返回當日起 14 天內避免到訪 Dr Motivate,任何人均不得轄免。 如閣下的健康狀況和旅遊史有任何變更,煩請在進行輔導前一個工作天通知我們。  

In view of the latest development of COVID-19, you are required to complete the health and travel declaration below one business day before your counselling session. Anyone (including airline crew and HK residents under the Return2hk Travel Scheme) who have returned or lives with anyone who has returned from overseas (including Macau and Mainland China) must refrain from visiting Dr Motivate for 14 days commencing their date of return. There are no exceptions to this requirement. Please update us in case there is any change in the condition stated in your health and travel declaration prior to your visit to Dr Motivate.

在此表格上資料只收集作 Dr Motivate 用途,絕不會與任何第三方共享。The information collected in this form is for Dr Motivate’s purpose only and never shared with any third party.
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Email *
姓名 Full Name *
電話 Phone Number *
強制申報 COMPULSORY DECLARATION
如果您對以下問題 1 至 4 中的任何一個回答選擇了“是”或無法填寫聲明表,您將不被接受輔導服務。If you have selected “Yes” to any of the Questions 1 to 4 below or are unable to complete the Declaration Form, you will not be accepted for the counselling service.
你或與你同住的人在過去 14 天內是否從海外(包括澳門和中國大陸)抵港?Have you or anyone you live with, arrived in Hong Kong from overseas (including Macau and Mainland China) in the past 14 days? *
如「是」,請說明來自哪個國家。If yes, kindly indicate from which country.
您是否與衛生防護中心強制居家隔離的人有密切接觸,或已被隔離? Have you been in close contact with someone who is on Mandatory Home Quarantine from the Centre For Health Protection, or have been issued one? *
您目前是否有發燒或呼吸道感染症狀(咳嗽、喉嚨痛、流鼻涕、流感、呼吸急促等)或在過去 14 天內有任何此類症狀? Are you currently experiencing fever or respiratory symptoms (cough, sore throat, runny nose, flu, shortness of breath etc.) or have had any such symptoms in the past 14 days? *
您在過去 14 天內是否感染了 COVID-19 並出院? Have you been infected with COVID-19 and discharged from the hospital in the past 14 days? *
聲明 Declaration *
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