有用資料

Reporting Form for Heavy Metal Poisoning
Particulars of Patient

Name in English:

Name in Chinese:

Age/Sex:

Address:	Telephone number:
Place of Work/School Attended:	Telephone number:
Hospital(s) attended:	Hosptial/A&E Number:

Heavy Metal Poisoning [" "] below suspected/confirmed on : / / (dd/mm/yr)

Lead

Mercury

Arsenic

Cadmium

Others; Please specify:

Levels in:

Urine:
Blood:
Other clinical samples (please specify):

Remarks:

Reported by:

Dr.		on	/ /
	(Full Name in BLOCK Letters)		(Date)
Telephone Number:
			(Signature)

The personal data provided by doctors to the Department of Health (DH) will be used for the public health control of heavy metal poisoning. All data provided will be kept strictly confidential. For enquiries, please call the respective Regional Offices at:

Hong Kong Regional Office	tel 2961 8729	fax 2572 7582
Kowloon Regional Office	tel 2199 9149	fax 2311 7537
New Territories East Regional Office	tel 2684 5138	fax 2603 0523
New Territories West Regional Office	tel 2615 8571	fax 2413 8812

有用資料

Reporting Form for Heavy Metal Poisoning Particulars of Patient

Reporting Form for Heavy Metal Poisoning
Particulars of Patient