本土人员（城工园全季）附有答案

本土人员（城工园全季）[复制]14天集中隔离人员填写1.房间号Room[填空题]*_________________________________2.姓名Name[填空题]*_________________________________3.性别Gender：[单选题]*○男man○女female4.年龄age[填空题]*_________________________________5.是否怀孕pregnantornot[单选题]*○是yes_________________*○否no依赖于第3题第2个选项6.是否为中国国籍Chinesenationalityornot[单选题]*○是yes○否no7.身份证号码[填空题]*_________________________________依赖于第6题第1个选项8.本人手机号码Phonenumber[填空题]*_________________________________9.国内具体住址（请按照：X省X市X区XX街镇X幢X号此格式填写）AddressinChina[填空题]*_________________________________10.国内地址所属区Domesticaddressarea[填空题]*_________________________________11.紧急联系人姓名Emergencycontactname[填空题]*_________________________________12.紧急联系人电话PhoneofEmergencyContactPerson[填空题]*_________________________________13.是否接触可疑病例[单选题]*○是○否14.是否来自中高风险地区Frommediumandhighriskareas[单选题]*○是yes○否no15.隔离期满后意向去向Intendplaceaftertheisolationperiod[单选题]*○留沪stayinshanghai○国内离沪domesticdeparturefromshanghai○其他_________________*16.隔离期满后上海的具体地址Addressinshanghai[填空题]*_________________________________依赖于第15题第1个选项17.目前健康状况healthcondition[单选题]*○发热fever○干咳drycough○乏力weak○咽痛sorethroat○胸痛胸闷chestpain○其他otherdiscomfortsymptoms○无以上异常症状health18.既往有无疾病史medicalhistory【请提前准备好相关病例证明，出示给医务人员审核】[填空题]*_________________________________19.本人承诺以上提供的资料真实准确。如有不实，本人愿意承担由此引起的一切后果及法律责任。Ipromisethattheinformationprovidedaboveistrueandaccurate.Ifitisuntrue,Iamwillingtobearallconsequencesandlegalliabilitiesarisingtherefrom.[单选题]*○同