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) Single (單身)Married (已婚)Divorced (離婚)Widowed (寡)Separated (分居)

Reason for referral (轉診心臟評估原因)

Past History (過去醫學史)

• Rheumatic Fever 風濕熱
• Heart Murmur 心臟雜音
• Heart Attack 心肌梗塞
• High Cholesterol 高膽固醇
• High Triglycerides 高甘油三酯
• High blood pressure 高血壓
• Diabetes 糖尿病

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

• Angiogram 血管攝影
• Stents 支架
• Heart Surgery 心臟手術
• Echocardiogram 心臟超音波
• Stress test 跑步測試
• Thallium scan/Nuclear scan 心肌灌注掃描
• Other 其他心臟檢查

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

• Yes
• Never 從來沒有

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

• Chest pain 胸痛
• Fainting/Dizziness 昏倒
• Indigestion 消化不良
• Breathing problems 呼吸問題
• Weight changes 體重變化
• Nervousness 緊張
• Others 其他

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) *

• Yes

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