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1、来访者健康问卷MEDICAL QUESTIONNAIRE姓名Name公司名称 （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 Please 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 i
2、nfectionsqqqqqqqq2. 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?qq3. 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
3、 or septic fingers 复发性的失聪，失明，龋齿/口中Recurring discharge from the ears, eyes, gums / mouth qqqqqqqq4. 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. .qq5. 最近三个月内是否曾经出国?Have you been abroad within the last 3 months?qq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打印名 Print Name日期 Date批准人Approved by职位Position
