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(中英双语)维也纳鹤洲集中隔离酒店信息采集表Health and Medical Information Collection Form(Vienna hezhou International Hotel )

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您是否怀孕?Are you pregnant?
否No
是Yes
您有无长期服用药物?Do you take any medication for a long time?
否No
是 (在下方空格处填写)Yes (Please fill in the blank place below)
(ISI)您最近1个月对目前的睡眠问题的担心/痛苦程度如何?In the past month, how worried/painful are you about your current sleep problems?
无 Asymptomatic
中度 Mild
一般 Moderate
重度 Severe
极重度 Extremely severe
(PHQ)在过去的两个星期里,感到心情低落、沮丧或绝望?In the past two weeks, did you feel unhappy, depressed, or hopeless?
无 None
几天 Several days
一半以上 More than half
几乎每天 Almost every day
(GAD)在过去的两个星期里,不安得难以静坐?In the past two weeks, have you been too upset to stay still?
无 None
几天 Several days
一半以上 More than half
几乎每天 Almost every day