新型冠狀病毒核酸檢測登記表格
Registration Form of COVID-19 RNA Test
(由醫生核實及轉介 For verification and referral by Doctor)
檢測者個人資料 Personal Details of Examinee
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示例圖片 Sample
男性 Male 女性 Female
風險評估問卷 Risk Assessment Questionnaire
  1. 過去14天您曾經居住或到訪過的城市 Cities that you have lived or visited in the past 14 days:
    中國內地城市,請指明 City in Mainland China, please specify: 其他,請指明 Others, please specify: 過去的14天內我並沒有離開香港
  2. 過去14天內您有否有與新型冠狀病毒確診者緊密接觸? Have you had close contact with COVID-19 infected person in the last 14 days?
    有 Yes 沒有 No
  3. 您的居住社區/工作環境有否新型冠狀病毒確診個案? Are there any confirmed cases of COVID-19 infection in the neighbourhood of your home /office?
    有,請指明 Yes, please specify: 沒有 No
  4. 您目前是否患有糖尿病、哮喘或高血壓等慢性疾病? Do you currently suffer from chronic diseases such as diabetes, asthma or high blood pressure?
    是 Yes 否 No
  5. 您有以下徵狀嗎? Do you have any of the following Symptoms?
    發燒 Fever 呼吸困難 Difficult to breathe 咳嗽 Cough 肌肉痠痛 Muscle Pain 肚瀉 diarrhea 胸口鬱悶 Chest Congestion 其他,請指明 Yes, please specify: 以上皆非 None of the above Symptoms
  6. 您現在懷孕嗎? Are you pregnant now?
    是 Yes 否 No
聲明Declaration
(如檢測者未滿18歲,須由家長或監護人簽署To be signed by a parent or guardian if the examinee is below 18)
本人確認上述所提供的資料準確無誤;且本人已閲讀及同意後頁所載的【收集個人資料聲明】。本人願意收取任何市場推廣資訊。
I confirm that the information provided above is accurate; and that I have read and consent to the "Personal Information Collection Statement"; and I agree to receive marketing, advertising and promotional information.
本人確認上述所提供的資料準確無誤;且本人已閲讀及同意後頁所載的【收集個人資料聲明】
I confirm that the information provided above is accurate; and that I have read and consent to the "Personal Information Collection Statement".
確認並提交
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