Please fill out your Name,budge No and Department请填写你的姓名，工号和部门
Do you need to work in the environment which is above 33 Celsius degree?你是否需要在33度以上的环境下工作？
No不用
Occasionally, less than one month per year偶尔，每年少于一个月
Often, more than one month per year经常，每年超过一个月
Diagnosed by the doctor, do you have the following disease?经过医院诊断，你是否患有以下 疾病？
Hypertension高血压
Chronic nephritis慢性肾炎
Hyperthyroidism甲状腺功能亢进症
Diabetes糖尿病
Epilepsy癫痫
None of above以上都没有。
Had you ever been with the following symptoms when you were working in the high temperature environment?在高温工作环境中工作过程中，你是否会出现过以下的症状？
Headache, dizzy头痛、头昏
Chest tightness胸闷
Palpitation心悸
Hyperhidrosis多汗
Intense heat or fever高热、发烧
Oliguria or anuria少尿或无尿
How often for the above symptom?出现以上症状的频率是多少？
Never没有发生过
Occasionally, once or twice偶尔一两次
Often经常发生
Did you take your time to drink the water or the herbal tea when you were working in the high temperature environment during the hot seasons?在高温季节，你是否在工作时抽空多喝开水或工厂提供的清凉凉茶？
Did you stay up for the irregular rest during the days you were working in the high temperature environment?在高温工作的日子，你是否会熬夜，不规律作息？
Seldom很少
Occasionally偶尔，少数时间会
Often, more than twice per week经常，每周多于两次
Did you miss your regular eating such as breakfast during the days you were working in the high temperature environment?你是否有三餐不规律进食，例如不吃早餐？
Seldom很少
Occasionally偶尔，少数时间会
Often, more than twice per week经常，每周多于两次
Did you drink a lot of alcohol during the days you were working in the high temperature environment?在高温工作的日子里，你是否会大量喝酒？
Seldom很少
Occasionally偶尔，少数时间会
Often, more than twice per week经常，每周多于两次
Do you know how to handle the employee who is suffering with heatstroke in the high temperature environment?你知道如果发生员工中暑后的应急处理方法吗？