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刍我健康状况监测表Personal HealthMonitoring Form,生名Name,护口1号Passport No.是否与核酸阳是否有发热、乏性人员有过近力、呼吸道不适是否服用退烧距离接触等疑似症状药、感冒药等Have youbeen inDo youhave any体温药物14天日期close contactsuspectedwith anyonewho symptomsofBody Haveyou taken14Days Datehas beentested infectionsuch asTemperatureany medicinepositivefor fever,fatigue orforfever ornucleicacid respiratorycold,etc.discomfort第天是Yes口否No□是YesD否No□是Yes口否No口第2天是Yes口否No□是YesD否No□是Yes口否No口Day2第3天是Yes口否No□是YesD否No□是Yes口否No口Day3第4天是Yes口否No□是YesD否No□是Yes口否No口Day4第5天是YesD否No□是YesD否No□是Yes口否No口Day5第6天是Yes口否No□是YesD否No□是YesD否NoDDay6第7天是Yes口否No□是YesD否No□是Yes口否No口Day7第8天是YesD否No□是YesD否No□是Yes口否No口Day8第9天是Yes口否No□是YesD否No□是Yes口否No口Day9第10天是Yes口否No□是YesD否No□是Yes口否No口Day10第11天是YesD否No□是YesD否No□是Yes口否No口Day11第12天是Yes口否No□是Yes口否No□是Yes口否No口Day12第13天是Yes口否No□是Yes口否No□是Yes口否No口Day14第14天是Yes口否No□是YesD否No□是Yes口否No口Day14本人保证以上填写信息真实、准确、完整,并知悉我将承担瞒报的法律后果I herebydeclare thatthe informationprovided aboveis true,accurate andcomplete,andI amaware ofthe legalconsequences inthe caseof partialor falsedisclosures.本人签名联系电话Signature TelephoneNumberD1ay1。