Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters.

陪探病預約

本問卷為匿名問卷。

除非問卷題目中有明確詢問您的個人資料,否則問卷不會記錄任何關於您的個人資料。

If you used an identifying token to access this survey, please rest assured that this token will not be stored together with your responses. It is managed in a separate database and will only be updated to indicate whether you did (or did not) complete this survey. There is no way of matching identification tokens with survey responses.

(本題必答)
病人姓名:
(本題必答)

陪探視病房:

(本題必答)
2病房床號:
(本題必答)
3病房床號:
(本題必答)
5病房床號:
(本題必答)
6病房床號:
(本題必答)
7病房床號:
(本題必答)
8病房床號:
(本題必答)
9病房床號:
(本題必答)
10病房床號:
(本題必答)
11病房床號:
(本題必答)
12病房床號:
(本題必答)
13病房床號:
(本題必答)

自費護理之家床號:

(本題必答)
呼吸照護病房床號:
(本題必答)
第2自費護理之家床號:
(本題必答)
18病房床號:
(本題必答)
日間照護中心床號:
(本題必答)
安寧病房床號:
(本題必答)
自費護家床號:
(本題必答)
ICU床號:
(本題必答)
陪探視日期:
Open date/time selector
(本題必答)
陪探視身分:
(本題必答)
探視
(本題必答)
陪病
(本題必答)
洗腎室接送
(本題必答)

陪探視者身份證字號/居留證:

(本題必答)
訪客姓名:
(本題必答)
訪客聯絡電話:
(本題必答)
目前身體不適症狀:
發燒度數
(本題必答)
旅遊史Travel history:最近1個月內旅遊史?
(本題必答)
職業別Occupation
(本題必答)
接觸史Contact history
(本題必答)
是否群聚Cluster:您近一個月內群聚史?
(本題必答)
同住家人正在
(本題必答)
到期日期:
Open date/time selector
備註: