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    Name*
    姓名
    Contact Number*
    联络电话

    Are you feeling unwell?
    您身体有感觉不适吗？YesNo

    Have you visited China in the last 14 days?
    您过去十四天去过中国吗? YesNo

    Did you have close contact with any person suspected with nVoC-19?
    您是否与任何怀疑感染 nCoV-19冠状病毒疾病的人吗?YesNo

    Body Temprature*
    体温