10/22/21, 3:11 PM 2016

Attachment   Health questionnaire (for storage)

 
2-4
 
name   dateofbirth Year Month Day
Affiliation/School
contact   Number  
current
 
residence
recent visit
 
 
dense area
 
 
 
1. Have you visited any foreign countries within the last 21 days? If yes, please write below.
□ Yes ( Country: Arrival Date: ) □ No                     

2. In the past 14 days, have you received a self-quarantine notice from a public health center
or have you been tested for COVID-19 in relation to a confirmed person with COVID-19?
  1) Whether COVID-19 diagnostic test is conducted □ Yes □ No ( Test date : )            
  2) Whether or not you have received a self-quarantine notice □ Yes □ No ( Receiving date: )   
         

3. If you have any of the following symptoms, please tick √ . (Duplicate possible)
□ Fever □ Muscle pain □ Cough, phlegm □ Runny nose, stuffy nose
□ Diarrhea □ Vomiting □ Sore throat □ Shortness of breath □ None

4. Have you recently met a person related to COVID-19 (ex. a confirmed case or a contact of a
confirmed case)?
□ Yes □ No
 

※ The above questionnaire should record only the facts.

 
Temperature Temperature Temperature Temperature
measurement (Day 1) measurement (day 2) measurement (Day 3) measurement (Day 4)
10 am 10 am 10 am 10 am

       
Temperature Temperature Temperature
measurement (day 5) measurement (Day 6) measurement (day 7)
10 am 10 am 10 am  

 
     
 ** 37.5 ˚ If you have respiratory symptoms such as fever over C, muscular pain, ingim Hutong, cough, please contact the Centers for Disease Control and
Safety Team 1339 or 2107. 
 
 
Posted on : 2021. . .            
 
By: (Signature)             
 

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