This set of questions will help us understand your medical history in order for us to provide the most appropriate, evidence-based effective treatment for your illness/health conditions. Every information shared on this form with your consultant is Private and Confidential. Thank you for your cooperation. 这一系列问题将帮助我们了解您的病史,以便我们为您的疾病/健康状况提供最适当的,有效治疗。在此表格上的所有資料均为机密。谢谢您的合作。
Email address *
Full Name 姓名 *
I/C or Passport 身份证号码 *
Gender 性别 *
Height (cm) 身高 *
Weight (kg) 体重 *
Marital Status
Clear selection
Mobile Contact 联络号码 *
Address 地址 *
Date of Birth ( YY / MM / DD ) 生日 (年/ 月/ 日) *
Do you have any medical illness? 您有任何疾病吗? *
If YES, what kind of medical illness? ( Eg. Gastrointestinal, Hypertension, High Cholesterol, etc) 如果有,请列下 (高血压,高胆固醇等)
Are you taking any form of medication? Please specify (including eye drops, nasal spray, patches, cream etc).您是否服用任何藥物嗎?如有,请列下
When was your last medical checkup? 您上次体检是什么时候? *
Are you taking any traditional medication(s) or supplements?(e.g. ginseng, dong guai) If YES, please specify 您是否服用任何中药或补品?(例如人参)如有,请列下 *
Do you have any of these conditions?您有以下嗎?
Do you drink alcohol? 您喝酒吗? *
Do you currently smoke / E-cig / Vape or come into contact with second-hand smoke? 您目前吸烟/电子烟/ Vape还是接触二手烟? *
Do you have any dietary habit 你有特別饮食习惯吗
Clear selection
How many times a week do you eat out? What do you usually eat? Eg. Fried food / Fast / Processed / Healthy您每周有几次外出就餐?你平时吃什么?例如,油炸食品/加工/健康
On average, how many servings of fresh fruit and vegetables do you eat in a day? (Keep in mind...One serving of fruits or vegetables is about the size of your fist.) 您平均每天吃多少份新鲜水果和蔬菜? (一份水果或蔬菜大约等于您的拳头大小。)
Clear selection
How many servings of calcium-rich foods do you typically eat in a day? (eg. dairy products, beans, green leafy vegetables, broccoli, almonds)您通常一天吃多少份富含钙的食物? (例如,乳制品,豆类,绿叶蔬菜,西兰花,杏仁)
Clear selection
How many servings of fish, rich in Omega-3 fatty acids, do you eat in a week?(eg. Salmon, sardines, tuna, Avocado) 您一周内吃多少份富含Omega-3的鱼?(例如鲑鱼,沙丁鱼,金枪鱼,鳄梨)
Clear selection
How is your appetite ? Any eating disorder? 您的食欲如何?有饮食問題吗?
Do you have any drug allergies? e.g. antibiotics /painkillers 您有药物过敏吗?例如抗生素/止痛药
Do you have any food allergies / lactose intolerant? E.g. milk/ nuts/shellfish 您有食物过敏/乳糖不耐症吗?例如牛奶/坚果/贝类
Do you have a family history of cardiovascular disease, hypertension, diabetes, high cholesterol ? 您是否有心血管疾病,高血压,糖尿病,高胆固醇的家族病史? *
Do you have a family history of cancer ( Prostate, Colon, Ovary , Skin ) ? 您是否有家族癌症史(前列腺癌,大肠癌,卵巢癌,皮肤癌)? *
Below questions are for female only 以下问题仅对女性
Are you pregnant ? 您怀孕吗 ?
Clear selection
Are you breastfeeding? 您在哺乳吗 ?
Clear selection
Are you Post-menopause? 您是否已更年期?
Clear selection
Preferred language / dialect for consultation 首选语言/方言进行咨询
What are your health concerns? 健康问题 *
Referred by ( Eg. Dr Wee / Pharmacist Mr Tan etc) 推荐人 *
I hereby declare that the details furnished above are true , accurate and complete to the best of my knowledge and belief and I undertake the responsibility to inform you of any changes therein, immediately.You have the right to access your personal data. If you would like to request access to your personal data, please contact us. We recommend that your request for access to your personal data held by Bespoke Health be made in writing. We may also take steps to verify your identity before fulfilling your request for access to your personal data.特此声明,以上提供的信息是真实,准确和完整的,并且我方有责任立即将其中的任何更改通知您。您有取得您的私人资料。如是,请与我们联系。我们建议您以书面形式提出您的请求。在满足您的请求之前,我们会验证您的身份。
Never submit passwords through Google Forms.
This form was created inside of Bespoke Health Sdn Bhd. Report Abuse