Astra Zeneca Vaccine – Health Screening Questionnaire (Chinese) / Astra Zeneca 疫苗接種的篩查問題
Date / 日期
Name / 姓名
IC No. / 身份证号码
Contact Number / 联系号码
Please (✔) if applicable / 如合宜 请（✔）
1. History of travel within the last 14 days / 14 天内旅游史
2. Currently on Quarantine Order (QO) or Self-Isolation Notice For Returning Travellers or any type of Self-Isolation Notice / 目前处于隔离或任何形式的自我隔离状态
3. Received notification to attend for COVID-19 swab via BruHealth application / 已收到COVID-19拭子检测通知
4. Close contact within the last 14 days with positive COVID-19 case (spending 15 minutes or more and within 1 metre distance) / 14 天内与COVID-19 阳性者密切接触史 (15分钟或更长时间，相距1米以内)
5. Living in the same household as someone currently on Quarantine Order / 与处于隔离期者同住
6. Spending time (no specified duration) at COVID-19 affected cluster area which is still active / 在COVID-19感染社区活动 (时段不限)
7. Have the following symptom: / 有以下症状:
7.1 Fever or history of fever / 发烧或发烧史
7.2 Cough, Runny nose and/or Sore throat / 咳嗽，流鼻涕和/或喉咙痛
7.3 Difficulty breathing / 呼吸困难
7.4 Diarrhoea / 腹泻
SCREENING QUESTIONS FOR ASTRAZENECA COVID-19 VACCINATION / 阿斯利康 COVID-19 疫苗接種的篩查問題
Please (✔) if applicable / 如有与以下任何一项合宜 请打钩(✔)
1. Current age (years) / 年龄
2. Current health status (e.g. having fever, flu-like illness, diarrhea, vomiting) / 目前身体状况 (比如 发烧，感冒，腹泻，呕吐)
3. Allergies to any vaccines previously / 任何种类疫苗过敏史
4. Pregnant / 妊娠期
5. Received any other vaccine within the last 2 weeks / 过去2周内接种过其它疫苗
If you ticked (✔) any one (1) or more of the above (any from Question 2 to 5), you CANNOT receive the vaccine. Please let staff know. / 如你 (✔)了任何一项或多项2-5所列项目，你不能接受此疫苗接种。請告知工作人员
6. History of organ or stem cells transplant (e.g. bone marrow transplant) / 器官或干细胞移植史 (比如骨髓移植)
7. Cancer on treatment / 癌症治疗期
8. On any Immunotherapy (e.g. for autoimmune diseases) / 任何种类免疫治疗期(比如 自身免疫性疾病治疗)
If you ticked (✔) to any one or more of the above (any from Question 6 to 8), you CANNOT receive the vaccine. Please let staff know. / 如你 ( ✔ )了任何一项或多项6-8所列项目，你不能接受此疫苗接种。 請告知工作人员
BRU-HIMS NO: / BRUHIMS 号码