會員健康狀況調查表 Member Health Questionnaire Preview Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.名字 Name *FirstLast性別 Gender *男 Male女 Female出生日期 Date of Birth *地址 AddressAddress Line 1Address Line 2CityState / Province / RegionPostal Code國家AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry聯絡電話 Phone *電子郵箱 Email *最常使用的即時通軟件 Most common use Instant Massaging *LineWhatsappFacebookKakaotalk微信 Wechat請提供 ID, Please provide your ID *即時通軟件的ID, Your IM ID身高 Height *體重 Weight *請問婚姻狀況 Marriage status已婚 Married未婚 Single請問有多少名孩子 How many child(s)請問分娩方式 Mode of delivery自然分娩 Natural childbirth剖腹 Caesarean section孕後增加體重 Weight after childbirth請問分娩後明顯變化 Any obvious changes after childbirth請問分娩後有否進行產後修復 Any postpartum recovery after giving birth?有 Yes沒有 No請敍術修復的方式 Method of restoration請問6個月內是否有懷孕計劃 Any pregnancy plans within 6 months?有 Yes沒有 No請問是否有婦科不適問題 Any gynecological discomforts?有 Yes沒有 No請問是否有生理期不適 Any discomfort during menstrual period?有 Yes沒有 No請問是否有接受過手術或治療 Ever had any surgery or treatment?有 Yes沒有 No請敍術接受過的手術或治療 Describe the surgeries or treatments you have received請問睡眠質素如何 How is your sleep quality?好 Good不好 No Good請敍術 Please describe請問是否有腸胃不適情況 Any gastrointestinal discomfort?有 Yes沒有 No請敍術 Please describe請問是否有心肺不適情況 Any cardiorespiratory discomfort?有 Yes沒有 No請敍術 Please describe請問脊椎是否有不適情況 Any discomfort in your spine?有 Yes沒有 No請敍術 Please describe請問慣用左手還是右手 You are left-handed or right-handed?左 Left右 Right請問手部是否有不適情況 Any discomfort in your hands?有 Yes沒有 No請敍術不適問題 Please describe請問腿部是否有不適情況 Any discomfort in your legs?有 Yes沒有 No請敍術不適問題 Please describe請問血壓是否正常 Blood pressure status標準 Standard高血壓 Hypertension低血壓 Hypotension請問血糖是否正常 Blood sugar level標準 Standard高血壓 Hyperglycemia低血壓 Hypoglycemia請問是否有骨質疏鬆 Do you have osteoporosis?有 Yes沒有 No請問是否有血動脈硬化 Any change in blood arteries?有 Yes沒有 No請敍術那個位置 Please describe請敍術 Please describe請敍術 Please describe請問是否有其他不適 (已有醫療檢查確認) Any other discomfort (has been confirmed by medical examination)有 Yes沒有 No請敍術 Please describe送出 Submit
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