Please check to indicate if you have ever had the following symptoms and conditions: 请检查以表明您是否曾经有过以下症状和情况：
Name
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NRIC
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example:801223145274
Gender
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Please Select
Male
Female
Contact Number
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example:60123456789
Email
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Checkup date
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Checkup date (show in form)
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Day
-
Month
Year
Date
Please check to indicate if you have ever had the following symptoms and conditions: 请查寻以下健康问卷
Cardiovascular related 心脏相关
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High blood pressure 高血压
High cholesterol 高胆固醇
Irregular heart beat or palpitation 心悸
Difficult in breathing 呼吸困难
Chest pain or discomfort 心胸痛
Stroke 中风
Tiredness or feeling weak 容易疲卷
Ankle or feet swelling 脚踝或足部肿胀
None of the above 非以上所有
Gastrointestinal related 肠胃相关
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Gastric 胃痛
Constipation 便秘
Stomach bloated 胃胀
Heart burn 胃灼热
Burping 打嗝
Rectal bleeding 直肠出血
Diarrhea 腹泻
Hemorrhoids 痔疮
None of the above 非以上所有
Hormone related 荷尔蒙相关
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Enlarged thyroid gland or a goiter 甲状腺肿
Irregular menstrual periods or stop having period 月经不调或月经周期停止
None of the above 非以上所有
Others 其他
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Dizziness 头晕
Insomnia 失眠
Decreased sex life 性欲下降
Anxiety, irritability and nervousness 感到焦虑, 烦躁和情绪波动
Aching muscles, joints or bone 肌肉, 关节或骨骼疼痛
Tingling sensation felt in your hands, feet, arms and legs 手, 脚, 手臂和腿有刺痛感
None of the above 非以上所有
Do you need nutritional consultation during check-up? 您需要营养师的咨询吗？
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Yes 要
No 不需要
Are you a Post Covid-19 patient ？您曾是新冠肺炎确诊者吗 ？
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No 无
Yes 有
Date of positive result 确认日期
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-
Day
-
Month
Year
Date
Please
IGNORE
the below questionnaire, if this is your 1st Check-up 如果这是您的第一次体检, 请略过以下问卷
Any recently diagnosed medical diseases 请更新您最近诊断的疾病:
Any medical updates in your family history since your last check up at GHHS 请更新您的家族病历史:
Any surgery updates since your last medical check up 自上次体检之后，您有做过任何手术吗:
List down all the regular medications and dosage that you are currently taking 列出您现在服用的药物和剂量:
Kindly inform us any other physical or psychological health related problems that you are currently experiencing 列出您现在所面对的任何身体与/或心理上的健康问题:
Last Menstruation Period (LMP) 上次经期首日日期:
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Day
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Month
Year
Menopause Age 停经岁数:
Number of Children (Parity) 子女人数:
Last Pap Smear Done (Date)最后一次子宫颈膜片检验(日期):
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Day
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Month
Year
Chinese Medical Health Assessment 中医健康评估
Physical Pain & numbness 身体疼痛和麻痹
Shoulder 肩膀
Lumbar 腰部
Head 头部
Lower limbs 下肢
Kidney related 肾脏问题
Kidney stone 肾结石
Gout pain 痛风
Urinary tract inflammation 泌尿系感染
Oedema / swelling due to water retention 水储留所导致的水肿或肿胀
Gynaecological Concern 妇科疾病
Uterine abnormalities 子宫异常 (肿块/肌瘤)
PCOS 多囊卵巢症
Adenomyosis 子宫腺肌症
Unusual bleeding & discharge 异常出血或带下
Breast Disorder (Breast pain etc) 乳房异常胀疼
Dysuria (Urinary Incontinence) 尿频
Men's Health Concern 男科疾病
Prostate enlargement 前列腺肿大
Urination difficulties 小便困难
Nocturia 夜尿
Erectile dysfunction 勃起障碍
Metabolic syndromes 新陈代谢问题
High visceral fat 内脏脂肪过高
Obese 肥胖
Fatigue 疲倦
Poor concentration 集中力低下
Poor appetite 食欲低下
Weak Muscle 肌肉无力
ENT 耳鼻喉科
Vertigo 眩晕
Tight throat 喉咙异物感
Phlegm 痰
Nasal congestion 鼻塞
Sinus 鼻窦炎
Eyes Sight issues 视觉问题
Dry Eyes 眼睛干涩
Floater (seeing floating spider web) 飞蚊症 （看到飘浮的蜘蛛网）
Seeing Flash 散光
Ocular Hypertension 眼压过高
I declare that the above information given is correct and complete 本人同意以上给予的资料是正确及完整的:
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