Young+ Wellness 尚醫健康 | Registration Form

身體檢查登記表格 Registration Form - Health Check

您確定資料準確無誤嗎？
Are you sure that the information is correct?

男性 Male

女性 Female

單身 Single

已婚 Married

一經確認，無法更改
Once confirmed, it cannot be changed

登記表格
Registration Form

檢測者個人資料 Personal Details of Customer

男性 Male

女性 Female

單身 Single

已婚 Married

健康問卷 Health Questionnaire

您目前是否患有下列疾病？ Do you currently suffer from the following diseases? 沒有任何 None 高血壓 Hypertension 糖尿病 Diabetes 心血管疾病 Cardiovascular Diseases 過敏性鼻炎/哮喘 Allergic Rhinitis/Asthma 皮膚疾病 Skin Disease 肝病 Liver Disease 腎臟疾病 Renal Disease 甲狀腺功能異常 Thyroid Dysfunction 其他 Others:
家族病史 Family Medical History
父系 Paternal
無 Nil 肥胖 Obesit 癌症 Cancer 糖尿病 Diabetes 高血壓 Hypertensio 認知障礙症 Alzheimer’s Disease 其他，請註明：Other, please specify:
母系 Maternal
無 Nil 肥胖 Obesit 癌症 Cancer 糖尿病 Diabetes 高血壓 Hypertensio 認知障礙症 Alzheimer’s Disease 其他，請註明：Other, please specify:
是否有定期服用藥物或保健品 Do you take medication or health supplements regularly?

藥物 Medication

保健品 Health Supplements
曾否做過手術 Have you had any surgery? 否 No 有，詳情 Yes, details:
手術年份 Year of surgery:
是否有過敏病史 Do you have any allergies? 否 No 有，詳情 Yes, details:
過往曾否進行身體檢查？ Have you ever had a physical examination in the past? 否 No 有，詳情 Yes, details:
最近一次檢查年份 Year of last inspection:

2019冠狀病毒相關 Related to COVID-19

過往曾否感染2019冠狀病毒？ Have you ever been infected with COVID-19 in the past? 否 No 有，康復日期 Yes, recovery date:

顧客健康狀況評估 Customer Health Status Evaluation

Please

the following symptoms if you have suffered for the past 2 weeks 如你過去2星期出現以下狀況，請

：

Dizziness 頭暈

Faintness 意識模糊

Headaches 頭痛

Insomnia 失眠

Migraine 偏頭痛

Earaches 耳痛

Ear infection 耳炎

Itchy ears 耳痕

Ringing in ears 耳鳴

Excessive mucus formation 流鼻水

Hay fever 花粉症

Rubbing nose all the time 經常揉鼻

Sensitive to odors 對氣味過份敏感

Sinus problems 鼻竇炎

Sneezing attacks 打噴嚏

Stuffy nose 鼻塞

Canker sores 口腔潰瘍

Chronic coughing 久咳

Dry Mouth 口乾

Gagging, frequent need to clear throat 痰多

Sore throat, hoarseness, loss of voice 喉痛，聲音沙啞或失聲

Swollen or discolord tongue, gums, lips 舌頭、牙肉或嘴唇腫/顏色變

Acne 暗瘡

Dry skin 皮膚乾燥

Eczema 濕疹

Hives 蕁麻疹

Irritation 皮膚過敏

Rashes 紅疹

Chest pain 胸口痛

High blood pressure 高血壓

Irregular or skipped heartbeat 心律不正

Rapid or pounding heartbeat 心悸

Asthma 哮喘

Bronchitis 支氣管炎

Chest congestion 胸口翳悶

Difficulty breathing 呼吸困難

Shortness of breath 呼吸短促

Belching 噯氣

Bloated feeling 胃氣或肚漲

Constipation 便秘

Diarrhea 腹瀉

Heartburn 胃灼熱

Intestinal/stomach pain 腸/胃痛

Nausea, vomiting 作嘔，嘔吐

Reflux 胃酸倒流

Leg aches 下肢痛

Pain or aches in joints 關節疼痛

Pain or aches in muscles 肌肉疼痛

Stiffness or limitation of movement 僵硬或活動困難

Arthritis 關節炎

Backache 背痛

Convulsive seizures 肌肉抽搐

Feeling of weakness or tiredness 感覺虛弱或疲勞

Binge eating/drinking 暴飲暴食

Compulsive eating 強迫性進食 (或受情緒影響)

Craving certain foods 偏食

Excessive weight 過重

Gain in weight 增重

Underweight 過輕++

Unexplained fluctuation of weight 不明原因體重波動

Water retention 水腫

Apathy 精神不掁

Difficulty waking up in morning 懶床

Fatigue 疲累

Lethargy 瞌睡

Sleepy after meals 餐後出現倦意

Sluggishness 呆滯

Craving for food, alcohol, or tobacco 渴求食物、酒精或香煙

Frequent illness 經常生病

Menstrual cramp 經痛

Premenstrual tension 經期前緊張

Others 其他：

聲明 Declaration

(如檢測者未滿18歲，須由家長或監護人簽署 To be signed by a parent or guardian if the Customer is below 18)

本人確認上述所提供的資料準確無誤；且本人已閲讀及同意後頁所載的【收集個人資料聲明】；且本人願意加入「尚醫會-會員計劃」，接收會員資訊及優惠。
I confirm that the information provided above is accurate; and that I have read and consent to the "Personal Information Collection Statement" as set out overleaf; and that I would like to join the "Young Plus Club - Membership Program" to receive member information and discounts.

確認並提交 Confirm and Submit

DNA WeCheck Limited / Young+ Wellness