Patient Screening Form  환자 스크리닝 양식
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Patient's Full Name *
Upcoming Appointment Date
Do you have fever or have you felt hot or feverish recently (14 days)? 현재 또는 근래에 (14일이내)몸에서 열이 나신적이 있습니까? *
Are you having shortness of breath or other difficulties breathing? 호흡이 가빠지시거나 숨쉬기 힘드신적이 있습니까? *
Do you have a cough? 기침을 하십니까? *
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? 독감증상 (속이 불편하신것, 두통, 무기력함 등)이 있습니까? *
Have you experienced recent loss of taste or smell? 근래에 냄새나 맛을 잘 못 느끼신적이 있습니까? *
Are you in contact with any confirmed COVID-19 positive patients? 코로나 확진 환자와 접촉하신적이 있습니까? (또는 가족중에 확진 환자가 있습니까?) *
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? 심장, 폐, 신장, 당뇨병 또는 어떤 자가면역 질환이 있습니까? *
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) 지난 14일이내에 다른곳에 여행하신적이 있습니까?
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How many doses for the COVID-19 vaccine have you received? 코로나 예방주사를 맞으셨나요? 맞으신 분은 몇번 맞으셨는지 답해주십시요. *
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