無恙諮詢個案表
All Is Well Customer Form
聯繫資訊 Contact Information
姓名 Name
電話 Phone
電子郵件 Email
郵寄地址 Shipping address
症狀調查 Investigation on symptoms
過敏 Allergies
Clear selection
睡眠障礙 Sleep disorders
Clear selection
口腔症狀 Oral symptoms
Clear selection
消化道問題 Gastrointestinal disorder
Clear selection
筋膜疼痛 Fascia Pain
Clear selection
其他疼痛症狀 Other Pain symptoms
其他身體不適 Other discomforts
治療調查 Investigation on treatments
目前服用什麼藥物?
What medicines you're taking now?
是否使用醫療用具(如正壓呼吸器、止鼾器、洗鼻器等)?
Do you use any medical equipments (i.e. CPAP, anti-snoring appliance, nasal irrigator, etc. )?
是否做過手術?
Have you had surgery?
是否做過睡眠檢測?睡眠呼吸中止程度為何?
Have you had sleep apnea test? Your AHI?
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