基本资料
姓名 ____________
身份证号 ____________
手机号 ____________
体温（°C） ____________
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疫情期间（近14天内）您有到过以下地方吗？
湖北或武汉
宝坻
其他明确的新冠肺炎疫区
其他病例报告社区
都没有
疫情期间（近14天内）您接触过以下地区来的人员吗？
湖北或武汉
宝坻
其他明确的新冠肺炎疫区
其他病例报告社区
都没有
疫情期间您接触过新型冠状病毒感染者（核酸检测阳性者）吗？
疫情期间，您是否接触过有发热、乏力、咳嗽、咽痛等呼吸道症状的患者？
疫情期间您有无家庭、办公室、同学等小范围出现内2例及以上发热和/或呼吸道症状的病例？
疫情期间您有何不适？
没有
发热
咳嗽
咽痛
乏力
腹泻/呕吐
鼻塞/流涕
出行信息
国籍/地区 ____________
护照（回乡证、通行证）号码 ____________
目的地 ____________
航班/船/车次号 ____________
座位号 ____________
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过去7天内您到过的国家和城市：
| 国家 | 城市 |
| ____________ | ____________ |
| ____________ | ____________ |
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过去7天内您是否与流感或有流感样症状的患者有过密切接触？
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您是否有以下症状和疾病
无
发热
咳嗽
嗓子痛（喉咙痛）
肌肉痛和关节痛
鼻塞
头痛
腹泻
呕吐
流鼻涕
呼吸困难
乏力
其他症状
Have you recently returned from outside China
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Personal information
Name ____________
ID card number ____________
Contact telephone number ____________
temperature（°C） ____________
Have you been to the following places during the outbreak (in the past 14 days)?
Hubei province or Wuhan City
Baodi District
Other novel coronavirus pneumonia cases
Other communities with novel coronavirus pneumonia confirmed cases report
None
During the outbreak (in the past 14 days), have you ever contacted the personnel from the following areas?
Hubei province or Wuhan City
Baodi District
Other novel coronavirus pneumonia cases
Other communities with novel coronavirus pneumonia confirmed cases report
None
Have you novel coronavirus (nucleic acid positive) infected persons during the epidemic?
During the epidemic, have you ever been exposed to patients with respiratory symptoms such as fever, fatigue, cough, sore throat, etc?
Do you live in a community with a confirmed (nucleic acid positive) patient?
Do your family members have any fever?
Do you have 2 or more cases of fever and / or respiratory symptoms in your family, office, classmates and other small areas during the epidemic?
Do you have the following symptoms during the outbreak
None
fever
cough
Sore throat
fatigue
Diarrhea / vomiting
Stuffy / runny nose
Entry-Exit Inspection and Quarantine of the P.R.China
Trip information
Nationality/Region ____________
Passport No. ____________
The destination ____________
Flight(boat/ train/bus)No. ____________
Seat No. ____________
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The itinerary of the next 7 days in China
Vechile of your next trip, Flight(boat/ train/bus)No.
Contact address of the next 7 days in China.
Contact telephone number （Residential or Business or Mobile or Hotel）
Contact information for the person who will best know where you are for the next 7days,in case of emergency or to provide critical health information to you ,please provide the name of a close personal contact or a work contact. This must NOT be you.
Name ____________
Telephone No. ____________
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If you leave China in 7 days, please fill in the Departure Date
Flight(boat/ train/bus)No.
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Please describe the countries and cities(towns) where you stayed within the last 7 days?
| country | city |
| ____________ | ____________ |
| ____________ | ____________ |
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Have you had close contact with patients of flu or person with flu-like symptoms within the last 7 days?
If you have the symptoms and diseases Please mark with “√” in the corresponding “□”
none
Fever
Cough
Sore
throat
Muscle and joint pain
Stuffy nose
Headache
Diarrhoea
Vomiting
Runny nose
Breath difficulty
Fatigue
Other symptoms