自我健康評估 / Health Self-assessment

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姓名 / Name *

日期 / Date *

YYYY

電話號碼 / Phone number *

1.你有否下列任何一種症狀? / Do you have any of the following symptoms? *

發燒 / Fever

咳嗽 / Coughing

呼吸困難 / Difficulty in breathing

喉嚨痛/吞嚥困難 / Sore throat /Difficulty in swallowing

流鼻涕 / Running nose

喪失味覺/嗅覺 / Loss of taste/smell

噁心/嘔吐/腹瀉 / Nausea/Vomiting/Diarrhea

以上皆非 / None of the above

Required

2. 在過去的14天裏,你是否與生病或已確診患有新冠狀肺炎的人有過接觸? / In the past 14 days, have you been in contact with someone who is sick or has been diagnosed with COVID-19? *

是 / Yes

否 / No

3. 在過去的14天裏,你是否從加拿大以外的地方旅行回來？/ In the past 14 days, have you returned from a trip outside Canada? *

是 / Yes

否 / No

4. 您是否已接種新冠狀肺炎的疫苗?/Have you been vaccinated? *

第一劑 / First Dose

第二劑 / Second Dose

沒有 / None

選擇不作答/ Prefer not to say

Other:

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