┌───────────────────────────────────────────┐
│ 体温： ℃ │
│ │
│ 健康申报表 │
│ Health Declaration │
│ │
│每位游客必须填写此表，交办理组团、接团手续的工作人员。 │
│如有身体不适，应立即向医疗部门报告 │
│Every tourist must complete this form and return it to receiving officer．If you have │
│uncomfortable，please report to the medical service at once │
│姓名 性别 男／女 │
│Name in full_____________________ Male／Female │
│国籍 身份证(护照)号码 │
│Nationality______________________ ID (Passport) NO．___________________ │
│到达日期 所乘航班(车次)号 │
│Date of Arrival__________________ Flight／train NO．___________________ │
│始发城市 │
│From City______________________________________ │
│1、此次旅行前14日您到过哪些国家和城市 │
│Please name the countries and cities that you have visited within the last 14 day’s │
│before arrival： │
│____________________________________________________________________________ │
│2、现如有以下症状，请在症状前的“□”内划“√”： │
│Please mark“√”in the item of following symptom if you have any one │
│ □发热(Fever) □咳嗽(Cough) │
│ □气喘(Shortness of breath) □呼吸困难(Breathing difficulty) │
│3、家庭住址 │
│Family Address____________________________________________________________________ │
│4、联系电话号码 │
│Contact telephone__________________________________________________________________ │
└───────────────────────────────────────────┘
