Health Inquiry Form 健康詢問表
Hi!

Are you REALLY serious about losing/gaining weight or shaping up or improving your health/skin condition to achieve your ideal and perfect body form? On average, we are able to help you to loss 5-15kg in 3 months without taking any medications or injections and and even exercises!! Can you believe it?!? When you are SERIOUS, everything is POSSIBLE! We can do it in a HEALTHY, EASY and yet EFFECTIVE way! If you are REALLY serious to change and transform yourself, please fill up this Health Inquiry Form. We will get back to you shortly after.

Thank you!

PS: If you are under the age of 18 and without parental consent & support, and with no urgency for any improvement in you, please do not fill in this form!!

您好

你是认真的想要减去或增加重量，或想要雕塑完美的体型，或改善你的健康或皮肤状况，以实现自己的理想完美身材吗？我們平均3個月可以幫你減去5~15kg噢 (不吃藥,不打針,不靠運動)!!当你是认真的时候，一切皆有可能！以一个健康，简单而有效的方式，我们都可以做到噢！如果你真的非常认真的想要改变或改造自己，请填写这个健康咨询表。我们会尽快给你联络。

谢谢！

PS: 未滿18歲的你, 沒有父母的同意&支持, 且無急迫改善者請勿填寫!!
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What is your full name? 您的全名是？ *
First name & Last name 姓名
How old are you? 你今年多大？ *
Your age 年齡
Which city and country are you residing in now? 你現在居住在哪個國家和城市？ *
Eg. California, USA   例如：美國加利福尼亞州
What is your contact number? 您的聯絡電話號碼是什麼？ *
Please provide the telephone or mobile phone number that I can easily contact you. Eg. +65 9876 5432 請提供我可以很容易地與您聯繫的電話或手機號碼。例如： +65 9876 5432
Do you have a SKYPE account? 你有SKYPE帳戶吗？ *
Please provide your User ID (SKYPE) for me to contact you easily. 請提供我可以很容易與您聯繫的SKYPE帳戶。
What is your email address? 您的電子郵件地址是什麼？ *
Please provide the email address that you most frequently check. 請提供您最經常檢阅的電子郵件地址。
When will be the ideal time to contact you? 與您聯繫的最理想的時間是？ *
What is your occupation? 你的職業是什麼？ *
Eg. Clerk, Housewife, Teacher, Student, etc 例如：文員，家庭主婦，教師，學生等
How tall are you? 你有多高？ *
Please indicate your height in cm. 請註明你的身高。
How heavy are you? 你有多重？ *
Please indicate your weight in kg. 請註明您的體重（公斤）。
Are you overweight or underweight? Why? 你超重或體重過輕吗？原因是？ *
Over eating, Genetics, After child birth/pregnancy, etc. Please indicate 'NA' if it is not applicable to you. 飲食过量，遺傳，生孩子/懷孕后等。 請註明“NA”，如果它並不適用於你。
How much weight do you intend to lose/gain? 你想减去/增加多少重量？ *
Please indicate in kg. 請註明（公斤）。
Did you ever try to lose/gain weight before? What method did you use? 你有嘗試过减重/增重嗎？ 你使用什麼方法呢？ *
Exercise, Diet, etc. 運動，飲食，等等。
Why do you want to make this major change now? What are your motivations? 你為什麼要現在要這个重大转變？你的推動力是什麼？ *
Want to wear small size clothings, Want to be healthy, etc 想穿小尺寸的衣服，健康，等
How determined and motivated are you? Choose from a range 1 to10. 您有多確定， 有多少推动力？请選擇1至10的範圍。 *
10 =  I am really very serious about lossing/gaining weight or improving health/skin condition & 1 = It does not matter if I do not lose/gain weight  or improve health/skin condition. 10 = 我是真的很认真，很想减重/增重或改善健康/皮膚狀況。 1 ＝ 我不是很在呼我能减重／增重多少或改善健康/皮膚狀況的， 這並不重要。
Do you stay up late often? 你經常熬夜嗎？ *
Definition of late: After 12 midnight. 熬夜的定义： 午夜12時之後。
Do you defecate/move your bowel everyday? Do you have constipation easily? 你有每天排便嗎？你会很容易就便秘嗎？ *
Once everyday, Once every alternate day, etc 每天一次，每隔一天一次，等
How much plain water are you drinking everyday? Do you drink at least 2 litres of plain water daily? 你每天喝多少開水？你每天会喝至少2公升的開水嗎？ *
3 litres plain water, 1 litre plain water, etc 3公升開水，1公升開水，等
How much do you normally spend on your breakfast? 你的早餐大概会花费多少？ *
What kind of food do you normally have for breakfast? This include drinks, fruits. 你早餐都吃些什麼？這包括飲料，水果。 *
How much do you normally spend on your lunch? 你的中餐大概会花费多少？ *
What kind of food do you normally have for lunch? This include drinks, fruits. 你中餐都吃些什麼？這包括飲料，水果。 *
How much do you normally spend on your dinner? 你的晚餐大概会花费多少？ *
What kind of food do you normally have for dinner? This include drinks, fruits. 你晚餐都吃些什麼？這包括飲料，水果。 *
Are you taking any medications/drugs like steroids or chronic disease drugs, contraceptives pills, etc? Do you have any endocrine disorders or any medical history? Please indicate the medications/drugs that you had taken before? 您有服用任何藥物如類固醇或慢性疾病藥物，避孕藥丸，等嗎？你有什麼內分泌失調或任何病史嗎？請列出你在食用的藥物？ *
Your health status: Do you ever have any of the following health conditions? 你的健康狀況： 你過去是否有以下健康状况？ *
You may choose more than 1. 你可以選擇超過一个選項。
Required
Are your family and/or friends against supplementing your daily diet with nutrition supplements? 你的家人和/或朋友会反對你食用營養補充劑嗎？ *
How much do you like to spend on nutrition supplements per month to see the change in you? 为了改变， 您每月肯花费多少在购买營養補充劑？ *
Please indicate in your currency $. 請註明您的貨幣$。
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