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
一經確認,無法更改
Once confirmed, it cannot be changed
身體檢查登記表格
Registration Form - Health Check
檢測者個人資料 Personal Details of Examinee
男性 Male 女性 Female
健康問卷 Health Questionnaire
  1. 您目前是否患有任何慢性疾病,例如糖尿病、哮喘或高血壓等?Do you currently suffer from any chronic diseases such as diabetes, asthma or hypertension?
    否 No 是,請指明 Yes, please specify:
  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 詳情 Yes, details:
  5. 是否有過敏病史 Do you have any allergies?
    否 No 詳情 Yes, details:
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 examinee 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】。本人願意收取任何市場推廣資訊。
I confirm that the information provided above is accurate. I have read and consent to the "Personal Information Collection Statement"; and agree to receive marketing, advertising and promotional information.
本人確認上述所提供的資料準確無誤;且僅用於檢測及後續個案跟進之用。本人並不同意收取任何市場推廣資訊。
I confirm that the information provided above is accurate. I understand that the information provided shall be used for testing and case follow-up purposes only. I do not consent to receive marketing, advertising and promotional information.
確認並提交 Confirm and Submit
DNA WeCheck Limited / Young+ Wellness