ASQ : CN New Patient registration

---Covid-19 Screening assessment---
---新型冠状病毒筛查---

Arrival Time
到达时间 *
Do you experience any of the following respiratory conditions in the last 14 days?
在过去14天内，您是否有以下任何呼吸道疾病？
Do you have a history of fever detected?
您有发烧史吗？ *
Have you been confirmed COVID-19 infected?
您是否曾经被确认感染了新型冠状病毒？ *
How are they treated?
治疗方式？ *
What is your medical history?
您的以往病史？ *
How is your diabetes control?
您的糖尿病控制得如何？ *
Do you need dialysis?
您需要透析吗？ *
Do you smoke?
吸烟史？ *
Do you drink alcohol?
饮酒史？ *
Do you currently taking any medicine?
您目前是否服用药物？ *
Do you need to take sleeping pill?
您是否需要服用安眠药？ *
For social security : Would you like us refer you to contracted hospital ?
社保方面：您希望我院把您转诊到签约医院吗？
COVID-19 Screening consent
新型冠状病毒筛查同意书 *
Please attach file for the COVID-19 test report
请附上新型冠状病毒测试报告文件
Maximum upload size: 6MB