國家衛生研究院員工健康自評表Health Self-Evaluation Form
姓名Name: 員工編號Staff ID:應徵單位Affiliation Unit:日期Date:
身高Height:________cm ; 體重Weight:________kg □否□是1.抽菸：每天支(包)，從歲開始；□已戒煙，曾經抽了___年。 □No□Yes 1. Smoking: How many packages of tobaccos every day? Since years old of beginning. □smoking cessation, smoking years before. □否□是2.喝酒：每星期約瓶，大都喝類酒，從歲開始□已戒酒，曾經喝了年。 □No□Yes 2.Drinking Alcohol? How much alcohol every week? What kind of liquor do you drink? Since years old of beginning. □drinking cessation, drinking years before. □否□是3.吃檳榔(betel nut)的習慣：曾經吃了年，從歲開始。 □No□Yes 3. Chewing betel nuts? Since years old of beginning. Chewing betel nuts years before. □否□是4.長期服藥：幾年，藥名 □No□Yes 4. Taking long-term medicine? years. Medicine:
□No□Yes 5. Allergic to medicine (food): □否□是6.是否曾患有內科疾病？疾病名稱： 曾於醫院治療，就醫日期：年月 □No□Yes 6. Have you ever contracted serious illness before? Diseases: . Treated in hospital. Date of cure: □否□是7.是否曾患有外科疾病、曾做過手術治療? 何種手術名稱：,於醫院治療， 就醫日期：年月
Surgery: . Treated in hospital. Date of cure: □否□是8.目前是否懷孕？第週。 □No□Yes 8. Are you pregnant at present? weeks. □否□是9.是否曾患有躁鬱症、憂鬱症等疾病？疾病名稱：曾於醫院治療，就醫日期：年月。
Disease: . Treatment in hospital. Date of cure: |
二、既往工作經歷work experience: A.是否從事過特殊作業? Have you ever engaged in the following working conditions? □No□Yes【□噪音noise、□游離輻射isotop、□鉛lead、□砷arsenic、□特殊化學物質接觸special chemical contact、□其他others 】 1.作業(部門)名稱：；公司名稱：；工作年限：自年月至年月。 2.作業(部門)名稱：；公司名稱：；工作年限：自年月至年月。 1.Department: Company: Between: (Y) (M)~ (Y) (M) 2.Department: Company: Between: (Y) (M)~ (Y) (M) B.是否長期操作電腦(每天超過四小時)? Have you ever used personal computer for a long time (more than four hours everyday)?□No□Yes
□頭痛(Headache) □咳嗽咳血(cough-blood) □心悸(palpitation) □食慾不振(poor appetite) □手指顫抖(tremble of finger) □顏面蒼白(pale with fear)□胃痛(stomachache) □痔瘡(piles) □頭暈(dizzy) □腹痛(bellyache) □腰痛(backache) □容易疲倦(tired) □手腳麻木(hand and foot asleep) □容易感冒(cold)□胸痛(a chest pain)□噁心(nausea) □便秘(constipation) □關節痛(ache in a joint)□傷口不易癒合(The wound is not easy to heal) □浮躁不安(Impetuous) □下肢浮腫(foot edema) □呼吸困難(breathe hard) □四肢無力(hand and foot feel weak) □失眠(insomnia)□嚴重貧血(bad anemic) □習慣性腹瀉(habitual dysentery) □耳鳴(tinnitus) □胸悶(The chest is stuffy) □其他(Others) |
健康自評表
四、家族疾病史(Family medical history)：【如有，請在□內打ˇ】(please tick)
| 本人 Myself | 父母 parents | 祖父母 grandparents (father's) | 外祖父母 grandparents (mother's) | 子女 Children | 兄弟姊妹 Sib |
1.高血壓Hypertension | □ | □ | □ | □ | □ | □ |
2.糖尿病Diabetes | □ | □ | □ | □ | □ | □ |
3.氣喘Asthma | □ | □ | □ | □ | □ | □ |
4.肺結核phthisis | □ | □ | □ | □ | □ | □ |
5.慢性腎臟病 Kidney disease | □ | □ | □ | □ | □ | □ |
6.血友病hemophilia | □ | □ | □ | □ | □ | □ |
7.心臟病Heart disease | □ | □ | □ | □ | □ | □ |
8.紅斑性狼瘡 systemic lupus erythematosus(SLE) | □ | □ | □ | □ | □ | □ |
9.癲癇Epilepsy | □ | □ | □ | □ | □ | □ |
10.精神分裂者Schiphonia | □ | □ | □ | □ | □ | □ |
11.癌症carcinomatosis __________ | □ | □ | □ | □ | □ | □ |
12.甲狀腺疾病Thyroid gland disease | □ | □ | □ | □ | □ | □ |
13.風濕性關節炎rheumarthritis | □ | □ | □ | □ | □ | □ |
14.眩暈症vertigo | □ | □ | □ | □ | □ | □ |
15.1 B型肝炎hepatitis B | □ | □ | □ | □ | □ | □ |
15.2 C型肝炎hepatitis C | □ | □ | □ | □ | □ | □ |
15.3 其他型肝炎Other hepatitis | □ | □ | □ | □ | □ | □ |
16.弱視amblyopia | □ | □ | □ | □ | □ | □ |
17.過敏性鼻炎allergic rhinitis | □ | □ | □ | □ | □ | □ |
18.胃或十二指腸潰瘍gastric/duodenal ulcer | □ | □ | □ | □ | □ | □ |
19.其他others | □ | □ | □ | □ | □ | □ |
本人已照實填寫以上員工健康自評表各項內容,本人同意財團法人國家衛生研究院審查本表所填各項資料，如有虛假，願受處分。 填寫人簽章：日期： I declare that the above health self-evaluation is true and correct. I agree that the above information to be verified by the National Health Research Institutes. Signature: _____________________________ Print Name: _____________________________ Date:_______________________________ | ||||||