新患者登記表 – 拳家草蘆

* = Required 必填

Contact Information 聯絡人資料

First Name 名 ^*

Last Name 姓 ^*

Gender 性別 ^* Male 男Female 女Other 其他Rather not say 不願透露

Date of Birth 出生日期 ^*

Weight 體重 ^*

Height 身高 ^*

Recent Photo 近期照片

Email 電郵 ^*

Home/Main Phone # 家庭/主要電話 ^*

Work Phone # 工作電話

Mobile Phone # 手機電話

Other Phone # 其它電話

Address 地址 ^*

Emergency Contact 緊急聯絡人

Name 姓名 ^*

Phone # 電話號碼 ^*

How/who were you referred to this clinic? 您是如何被推薦到本醫館的？ ^*

Current Health Status 現况：

What is the main purpose of your visit to this clinic? 您來本醫館的主要目的是什麽？ ^*

What other concerns do you have about your health? 您對自己的健康狀况還有哪些其它擔憂？ ^*

What medications are you currently taking? 你現在正在服用哪些藥物？ ^*

Please briefly fill in any information not mentioned in the above form but that you think the doctor needs to know: 請簡要填寫任何以上表格未提及、但你認為醫生須瞭解的情況：

Thank you for taking the time to provide this information. This information will greatly help us understand your current health status and choose appropriate methods to improve your health. 感謝您花費時間提供這些信息。這些信息將極大地幫助我們瞭解你的健康現狀，并為改進您的健康狀況選擇適當的方法。

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