ASQ : CN New Patient registration

---Covid-19 Screening assessment---

Arrival Time
到达时间 *
Do you experience any of the following respiratory conditions in the last 14 days?
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 ?
COVID-19 Screening consent
新型冠状病毒筛查同意书 *
Please attach file for the COVID-19 test report
Maximum upload size: 6MB
Have you ever receive Covid-19 vaccination?
您是否已注射COVID-19疫苗? *
Please attach file for the COVID-19 vaccination certificate
Maximum upload size: 6MB