文档介绍：1. Have our ever had or been a carrier of
yes
no
曾经有或是以下病毒携带者
是
否
A food borne disease 一种食物带来的疾病
□
□
Typhoid or1. Have our ever had or been a carrier of
yes
no
曾经有或是以下病毒携带者
是
否
A food borne disease 一种食物带来的疾病
□
□
Typhoid or paratyphold 伤害或副伤寒
□
□
Tuberculosis 肺结核
□
□
Parasitic infections 寄生虫传染病
any close family suffered from any of the above?
□
□
你的任何一位家人是否有遭受到以上疾病？
you or any close contact suffered from any of the following?
□
□
你和你接触的人是否曾遭受以下痛苦？
Recurring serious diarrhoea or vomiting
□
□
复发性严重的腹泻和呕吐
Recurring skin trouble
□
□
复发性的皮肤病
Recurring bolls , sites or septic fingers、sties
□
□
复发性的疥子或糜烂性手指
□
□
□
□
Medical Questionnaire of Visitor
外来人员健康问卷
Name
姓名
Company Name(If Applicable)
公司名称(如果可以告知)_
Contact at Site
联系地址
Reason for Visit
来访原因
please V applicable box
请在相应格内打V
Recurring discharge from the ears, eyes, gums 复发性的失聪，失明或龋齿/ 口中
Please give details of any other medical