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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 )

期待您的参与！现在我们就马上开始吧！
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)
您是否曾经确诊以下精神疾病？（Have you ever suffered from the following diseases?）
抑郁症depression
焦虑症Anxiety disorder
自伤自杀行为或想法autolesion
精神分裂症schizophrenia
双相情感障碍Bipolar Disorder
偏执型精神病Paranoid psychosis
精神发育迟缓mental retardation
药物所致精神障碍mental disorder
其他精神疾病（在下方空格处填写）mental illness
以上均无NONe
(ISI)您最近1个月认为您的失眠在多大程度上影响了你的日常功能 ？In the past one month, to what extent do you think your insomnia has affected your body functions in daily life?
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，做事时没有兴趣或乐趣 ？During the past two weeks, did you have no interest or pleasure in doing things?
无 None
几天 Several days
一半以上 More than half
几乎每天 Almost every day
(PHQ)在过去的两个星期里，有不如死掉的想法或以某种方式伤害自己的念头？In the past two weeks, did you have any thought s that you might as well die or hurt yourself in some way?
无 None
几天 Several days
一半以上 More than half
几乎每天 Almost every day
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