本土人員（城工園全季）[復(fù)制]14天集中隔離人員填寫1.房間號(hào)Room[填空題]*_________________________________2.姓名Name[填空題]*_________________________________3.性別Gender：[單選題]*○男man○女female4.年齡age[填空題]*_________________________________5.是否懷孕pregnantornot[單選題]*○是yes_________________*○否no依賴于第3題第2個(gè)選項(xiàng)6.是否為中國(guó)國(guó)籍Chinesenationalityornot[單選題]*○是yes○否no7.身份證號(hào)碼[填空題]*_________________________________依賴于第6題第1個(gè)選項(xiàng)8.本人手機(jī)號(hào)碼Phonenumber[填空題]*_________________________________9.國(guó)內(nèi)具體住址（請(qǐng)按照：X省X市X區(qū)XX街鎮(zhèn)X幢X號(hào)此格式填寫）AddressinChina[填空題]*_________________________________10.國(guó)內(nèi)地址所屬區(qū)Domesticaddressarea[填空題]*_________________________________11.緊急聯(lián)系人姓名Emergencycontactname[填空題]*_________________________________12.緊急聯(lián)系人電話PhoneofEmergencyContactPerson[填空題]*_________________________________13.是否接觸可疑病例[單選題]*○是○否14.是否來(lái)自中高風(fēng)險(xiǎn)地區(qū)Frommediumandhighriskareas[單選題]*○是yes○否no15.隔離期滿后意向去向Intendplaceaftertheisolationperiod[單選題]*○留滬stayinshanghai○國(guó)內(nèi)離滬domesticdeparturefromshanghai○其他_________________*16.隔離期滿后上海的具體地址Addressinshanghai[填空題]*_________________________________依賴于第15題第1個(gè)選項(xiàng)17.目前健康狀況healthcondition[單選題]*○發(fā)熱fever○干咳drycough○乏力weak○咽痛sorethroat○胸痛胸悶chestpain○其他otherdiscomfortsymptoms○無(wú)以上異常癥狀health18.既往有無(wú)疾病史medicalhistory【請(qǐng)?zhí)崆皽?zhǔn)備好相關(guān)病例證明，出示給醫(yī)務(wù)人員審核】[填空題]*_________________________________19.本人承諾以上提供的資料真實(shí)準(zhǔn)確。如有不實(shí)，本人愿意承擔(dān)由此引起的一切后果及法律責(zé)任。Ipromisethattheinformationprovidedaboveistrueandaccurate.Ifitisuntrue,Iamwillingtobearallconsequencesandlegalliabilitiesarisingtherefrom.[單選題]*○同