入住调查问卷 Check-In Questionnaire Simplified Chinese

入住调查问卷 Check-In Questionnaire Simplified Chinese
患者姓名 (Patient's Name)*

名 (First Name)姓 (Last Name)
出生日期 (Date of Birth)*

MonthDayYear
Date
今天陪同患者的人 (Name of the escort)*

名 (First Name)姓 (Last Name)
陪同人与患者的关系 (选择所有适用项) Relationship of the escort to the patient*

配偶 (spouse)父母 (parent)亲戚 (relative)法定监护人 (legal guardian)其他 (other)
请确保您和您的陪同人员已阅读并理解麻醉后说明：

https://ef5de842-ddd1-490d-b0c4-79bbf32359ef.usrfiles.com/ugd/ef5de8_60a4e462ad8d4c53a59e58a6933eceb8.pdf
请输入您的电子邮件地址。我们将通过电子邮件向您发送麻醉后说明。(Please enter your email address. We will email you the post-anesthesia instructions):
example@example.com
请注意，麻醉期间胃中的食物或饮料可能危及患者的安全，甚至危及患者的生命。

未成年患者父母/监护人须知：

为了您孩子的安全，如有以下情况，请务必告知我们：

1) 您的孩子（患者）无意或意外地吃或喝了任何东西。

2) 您的孩子（患者）没有受到父母/监护人的直接监护的情况（例如参加日托、学校等）.
患者在过去 12 小时内是否吃过或喝过任何东西? (did the patient eat or drink anything within the last 12 hours?)*

是 (yes)我不知道，因为患者没有受到监控 (I don't know because the patient was not monitored)否 (no)
[重要且关键] 请说明患者吃了什么或喝了什么，并说明时间 [IMPORTANT AND CRITICAL] (Please explain what the patient ate or drank, and specify the times)*
请检查患者过去 2 周出现的任何症状 (Please check any symptoms the patient has had in the past 2 weeks)*

无 (none)咳嗽 (coughing)鼻塞 (congestion)流鼻涕 (runny nose)发烧 (fever)寒冷 (chills)味觉丧失 (loss of taste)咽喉痛 (sore throat)感冒 (had the cold(流感 (had the flu)COVID-19其他 (other)
患者的家属是否曾经历过麻醉并发症？(Has any family members of the patient experienced any complications to anesthesia?)*

是 (yes)否 (no)
解释 (Explaination)*
患者有可能怀孕吗？(is there any possibility that the patient may be pregnant?)*

是 (yes)否 (no)不适用 (not Applicable)
谁在填写此表格？ (who is completing this form?)*

患者本人 (the patient himself/herself)上述陪同人员 (the escort indicated above)其他 (other)
签名 (signature)*

Clear
我证明上述陈述据我所知均属实，任何虚假信息、遗漏或失实陈述都可能对患者在麻醉期间造成致命风险。
Should be Empty: