食品工厂外来人员健康问卷

XXXX有限公司外来人员健康问卷

MEDICAL QUESTIONNAIRE OF XXXX co.,Ltd.

姓名Name

单位名称（如果可以告

知）Company Name

(if applicable)

联系地址Contact at Site

来访原由Reason for Visit

请在相应表格内打√

Please√applicable box

是否

1.是否是以下病毒携带者Have our ever had or been a carrier of:Yes No

由于食物引起的疾病A food borne disease□□伤寒或副伤寒Typhoid or paratyphoid□□肺结核Tuberculosis□□寄生性传染病Parasitic infections□□

2.你的任何一位家人是否有以上疾病？

Has any close family suffered from any of the above?□□

3.你或你的亲人是否曾有以下疾病引起的痛苦?

Have you or any close contact suffered from any of the following?

复发性严重的腹泻和呕吐Recurring serious diarrhoea or vomiting□□复发性的皮肤病Recurring skin trouble□□复发性的疖子,睑腺炎或糜烂性手指Recurring boils,sties or septic fingers□□复发性的失聪，失明，龋齿Recurring discharge from the ears,eyes,□□gums/mouth

4.请具体给出任何其它医疗问题，这些问题可能会导致你不能进入食品

类车间,例如，复发性的肠胃失调。Please give details of any other medical

problems which may affect your employment as a food handler,for example,□□recurring gastrointestinal disorder..

5.最近三个月内是否曾经出国?Have you been abroad within the last3□□

months?

如果有，哪里?If Yes,where?

我声明上述陈述均真实并尽我所知的完成此调查表.I declare that all foregoing statements

are true and complete to the best of my knowledge and belief.

填写人Signed日期Date

批准人Approved by职位Position