New Patient Form Chinese

Personal Details
Name/名称: Date:/ 日期

Address/地址:
Phone/电话
Emergency Contact: 紧急联系人
Occupation, 占用
Who recommended you? 谁推荐你
Email Address:/ 电子邮件地址

Reasons For Care: 护理的理由？

Primary Health Complaint(s) 初级卫生投诉

When did the pain start? 疼痛什么时候开始的？

Circle- Is the pain Sharp, Dull, Throbbing, Ache

圈 - 是痛苦尖锐，无聊，悸动，疼痛

Circle- is the pain getting better, worse, staying the same

圈子 - 痛苦越来越好，更糟的是，保持不变

Circle- how often does it occur: constantly, daily, on and off

圈子 - 多久出现一次：不断地，每天一次，一次又一次地

What do you think caused this problem?

你觉得这个问题是什么造成的？

Have you had this condition previously? Yes/No If yes, when?

你以前有过这种情况吗？是/否如果是，何时？
 Please list any previous health practitioners name(s) 请列出任何以前的健康从业者姓
名（S）

No /
Have you ever: 你有没有？ Briefly Explain
Yes
Broken bones? 破骨头？
Been hospitalized? 住院了？
Been in an auto accident? Had
Sprains/Strains? 在发生车祸？有扭曲/
菌株？
Been struck unconscious? Had surgery?
被打到昏迷？有手术吗？

Family History
Family Members - Present and past health conditions (Example: heart disease, cancer,
diabetes, arthritis, etc.) 家庭成员 - 当前和过去的健康状况（例如：心脏病，癌症，糖
尿病，关节炎等）

Please Tick
Habits None Light Moderate Heavy
Alcohol/醇
Coffee/咖啡
Tobacco/烟草
Drugs/毒品
Exercise/行使
Sleep/睡觉
Appetite/食欲
Soft Drinks/软饮料
Water/水
Salty Foods/咸的食物
Sugary Foods Artificial/含糖
食物
Sweeteners /人造甜味剂

Do you experience pain every day? No Yes

你每天都经历痛苦吗？
Do your symptoms interfere with daily life? No Yes

你的症状是否影响日常生活？
Does pain wake you up at night? No Yes

晚上疼痛会让你起床吗？
Are your symptoms worse during certain No Yes
times of the day? Do changes in weather
affect your symptoms?

你的症状在一天中的某些时候会恶化吗
？天气的变化是否会影响你的症状？

Do you wear orthotics? No Yes

你穿矫形器吗？
Do you take vitamin supplements? No Yes

你服用维生素补充剂吗？
What activities aggravate your symptoms?

什么活动加重你的症状？

Please tick any boxes for conditions for which you may have been treated:

请圈出您可能受到的任何条件：
酒精中毒过敏贫血动脉硬化关节炎哮喘大便疼痛乳房肿块支气管炎瘀伤容易癌症胸
部疼痛/情况四肢便秘痉挛抑郁症糖尿病消化问题头晕耳环过度月经眼睛疼痛疲劳频
繁排尿头痛痔疮高血压潮热不规则心脏跳动不规则周期肾脏感染肾结石损失记忆力
丧失平衡力丧失的味道丧失

乳房颈部疼痛或僵硬神经质鼻血起搏器小儿麻痹坐姿坐骨神经痛呼吸急促静脉窦感
染睡眠问题脊柱弯曲中风踝关节肿胀肿胀关节甲状腺疾病结核性溃疡

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dàbiàn téngtòng rǔfáng zhǒngkuài zhīqìguǎn yán yū shāng róngyì áizhèng
xiōngbù téngtòng/qíngkuàng sìzhī biànmì jìngluán yìyù zhèng tángniàobìng
xiāohuà wèntí tóuyūn ěrhuán guòdù yuèjīng yǎnjīng téngtòng píláo pínfán
páiniào tóutòng zhìchuāng gāo xiěyā cháo rè bù guīzé xīnzàng tiàodòng bù
guīzé zhōuqí shènzàng gǎnrǎn shèn jiéshí sǔnshī jìyìlì sàngshī pínghéng lì
sàngshī de wèidào sàngshī

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