新型冠狀病毒核酸檢測登記表格
Registration Form of COVID-19 RNA Test
（由醫生核實及轉介 For verification and referral by Doctor）
檢測者個人資料 Personal Details of Examinee
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 example
示例圖片 Sample
 Throat swab 咽拭子 Deep Throat Saliva 深喉唾液 Nasopharyngeal swab 鼻咽拭子 Combined Nasal & throat swab 合併鼻及咽拭子 Others(Please specify) 其他(請註明): 男性 Male 女性 Female
風險評估問卷 Risk Assessment Questionnaire
  1. 過去14天您曾經居住或到訪過的城市 Cities that you have lived or visited in the past 14 days:
    中國內地城市，請指明 City in Mainland China, please specify: 其他，請指明 Others, please specify: 過去的14天內我並沒有離開香港 I have not left Hong Kong in the past 14 days.
  2. 過去14天內您有否有與新型冠狀病毒確診者緊密接觸? Have you had close contact with COVID-19 infected person in the last 14 days?
    有 Yes 沒有 No
  3. 您的居住社區/工作環境有否新型冠狀病毒確診個案? Are there any confirmed cases of COVID-19 infection in the neighbourhood of your home /office?
    有，請指明 Yes, please specify: 沒有 No
  4. 您目前是否患有糖尿病、哮喘或高血壓等慢性疾病? Do you currently suffer from chronic diseases such as diabetes, asthma or high blood pressure?
    是 Yes 否 No
  5. 您有以下徵狀嗎? Do you have any of the following Symptoms?
    發燒 Fever 呼吸困難 Difficult to breathe 咳嗽 Cough 肌肉痠痛 Muscle Pain 肚瀉 diarrhea 胸口鬱悶 Chest Congestion 其他，請指明 Yes, please specify: 以上皆非 None of the above Symptoms
  6. 您現在懷孕嗎? Are you pregnant now?
    是 Yes 否 No
聲明Declaration
(如檢測者未滿18歲，須由家長或監護人簽署To be signed by a parent or guardian if the examinee is below 18)
本人確認上述所提供的資料準確無誤；且本人已閲讀及同意後頁所載的【收集個人資料聲明】。本人願意收取任何市場推廣資訊。
I confirm that the information provided above is accurate; and that I have read and consent to the "Personal Information Collection Statement"； and I agree to receive marketing, advertising and promotional information. 本人確認上述所提供的資料準確無誤，並不同意提供我的個人資料给予有關單位更新資訊及進行推廣相關活動之用途，本表格所收集的個人資料僅用於檢測之用。
I confirm that the information provided above is accurate; and I do not consent to receive the update promotion from the related organisations.
確認並提交 Confirm and Submit
DNA WeCheck Limited / Young+ Wellness