Health Questionnaire for HK Digestive Health Centre
Please fill out the below information as completely as possible. If you need help, please feel free to call us at 3619 5220 so we may assist you. The survey will take you approximately 10-15 minutes to fill out. If you do not know the answers to some questions you may skip them.

After you fill out and submit the Questionnaire, we will contact you within two business days.
Family Name or Surname *
First Name *
Chinese name (if applicable)
Date of birth
MM
/
DD
/
YYYY
Gender
Clear selection
Ethnicity
Telephone number *
Email *
What is the best way to contact you? *
HKID (or other ID card)
Address
Height
Weight
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