Self-Health Checklist
Student ID no/ Employee ID no.（※）Faculty/Department () Name（）Age（）Sex（Male・Female）

If you have fever (≧37.5 degrees) and respiratory symptoms (cough, sputum, shortness of breath, etc), Please contact Health Service Center.

Matsue:Tel:0852-32-6568 (Extension 2801), Mail: health@soc.shimane-u.ac.jp
Izumo：Tel:0853-20-2099, Mail:satoezoe@med.shimane-u.ac.jp
rdDate: Jan 23 Fri←1/23(Fri)
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Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)

Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Shortness of breath (yes/no)

Shortness of breath (yes/no)

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Shortness of breath (yes/no)

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Shortness of breath (yes/no)

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Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

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Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Shortness of breath (yes/no)

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Congestion/sneezing (yes/no)

Congestion/sneezing (yes/no)

Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Coughings(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Phlegm(yes/no)Shortness of breath (yes/no)

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