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.
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
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
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
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屬於提交樣本的檢測者本人並準確無誤；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 belongs to the examinee submitting the specimen and is accurate. I have read and consent to the "Personal Information Collection Statement"; and agree to receive marketing, advertising and promotional information.
本人確認上述所提供的資料屬於提交樣本的檢測者本人並準確無誤； 且僅用於檢測及後續個案跟進之用。本人並不同意收取任何市場推廣資訊。
I confirm that the information provided above belongs to the examinee submitting the specimen and is accurate. I understand that the information provided shall be used for testing and case follow-up purposes only. I do not consent to receive marketing, advertising and promotional information.
