新病患問卷 Patient information (Chinese) – HEART HEALTH SPECIALIST CENTRE

新病患問卷

First Name (名): *

Last Name (姓) *

Date of Birth (生日) *

Country of Birth (出生國家)

Address (住家地址)

Phone (Home and/or mobile) (電話) *

Occupation (工作)

Email (郵件信箱) *

Next of Kin (緊急聯絡人) *

Marital Status (婚姻狀態)

Reason for referral (轉診心臟評估原因)

Past History (過去醫學史)

Have you had the following tests before? 之前有沒有做過以下的測試

Have you had previous surgeries? 以前有沒有做過其他手術

Any allergies 過敏 *

Have you ever smoked Cigarettes? 有沒有吸過菸

If yes, how many packets a day for how many years (如果有抽菸, 每天幾包菸, 抽幾年)

Family medical history 家庭病史

Do you have any of the following symptoms 有沒有以下症狀

By submitting this form, you agree that the information provided on this form is true and accurate. (通過提交此表格，您同意本表格提供的信息真實準確) *

Email

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