外来人员健康问卷(中英文版).doc

******************************公司外来人员健康问卷
MEDICAL QUESTIONNAIRE OF QINGDAO NINE-ALLIANCE GROUP CO.,LTD. COLD STORAGE FACTORY
编号：***RL-D-007-170
姓名Name

单位名称 （如果可以告知）Company Name (if applicable)

联系地址
Contact at Site

来访原由
Reason for Visit

请在相应格内打Ö
Please Ö applicable box

是

否
1. 曾经有或是以下病毒携带者 Have our ever had or been a carrier of:
Yes

No
一种食物带来的疾病 A food borne disease
伤寒或副伤寒 Typhoid or paratyphoid
肺结核 Tuberculosis
寄生性传染病 Parasitic infections
q
q
q
q

q
q
q
q

2. 你的任何一位家人是否有遭受到以上疾病？
Has any close family suffered from any of the above?
q

q
3. 你或你周围的人是否曾遭受以下痛苦?
Have you or any close contact suffered from any of the following?

复发性严重的腹泻和呕吐 Recurring serious diarrhoea or vomiting
复发性的皮肤病 Recurring skin trouble
复发性的疖子,睑腺炎或糜烂性手指Recurring boils, sties or septic fingers
复发性的失聪，失明，龋齿/口中Recurring discharge from the ears, eyes, gums / mouth
q
q
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q

q
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4. 请具体给出任何其它医疗问题，这些问题可能会影响你成为一个合格的食品类员工,例如，复发性的肠胃失调。Please give details of any other medical problems which may affect your employment as a food handler, for example, recurring gastrointestinal disorder. .

q

q

5. 最近三个月内是否曾经出国?Have you been abroad within the last 3 months?
q

q
如果有，哪里?
If Yes, where?

我声明上述陈述均真实并尽我所知的完成此调查表. I declare that all foregoing statements are true and complete to the best of my knowledge and belief.
填写人 Signed

日期 Date

批准人Approved by

职位Position