您確定資料準確無誤嗎？
Are you sure that the information is correct?
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男性 Male
女性 Female
單身 Single
已婚 Married
身體檢查登記表格
Registration Form - Health Check
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
  1. 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:
  2. 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:
  3. 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
  4. 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:
  5. 是否有過敏病史 Do you have any allergies? 否 No 有，詳情 Yes, details:
  6. 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
  1. 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 Senstiivity 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