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Hospital Health Question Form
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Please print and fill in the form before coming to the hospital.

Patient Information

(Please Print If Using English)

 

Date - _____________

 

Name – (Chinese) - __________________(English)_________________________ 

        

Sex - ____________Date of Birth - __________________ Age –_______________

 

Address – ____________________________________________________________________

_____________________________________________________________________________

 

Home Telephone Number -________________________ Mobile Number –_______________

Work Number –______________________Ext-___________

 

Employer -___________________________________________________________                             

 

Job / (Title and description) –_____________________________________________________

 

Primary complaint / reason for your visit today –_____________________________________

__________________________________________________________________________

_________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

History of this illness or problem, (Have you had this before? When did this start?) – _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Medical History of ANY conditions 

(Including surgeries, births hospitalizations, psychiatric/psychological and when?)_________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

Smoking? – ___________(If yes, how long and how much per day)______________

 

Alcohol Use? -__________(If yes, how much of what and for how long)___________

 

Are you allergic to any medicines? – _________If yes, what medicines? -_________________

_______________________________________________________________________________________________________________________________________________________

 

Any other allergies? –____________________________________________________________

_____________________________________________________________________________________________________________________________________________________

 

What medicines are you taking now, the amount(s) and for how long? –__________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Have you ever taken psychiatric medicines?______________

If yes, what medicines did you take? How long and how much? Was it helpful? – __________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Family history of medical illnesses?  (Including psychiatric/psychological problems) -_____

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

If this is a psychological visit, what do you hope/want to accomplish in seeking help? -______

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Married / Single / Divorced / Engaged - _______________________________

If Married, how long __________________________________________

Children – How many - ________________________________________

Ages - _______________________________________________________

 

If foreigner

 

How long have you been in China? ________________________________________________                   

How long will you stay in China?__________________________________________________

 

 

 

Current Vital Signs :

 

T - ____________P- ___________R- ____________________B/P- ________________  

        

Ht- ____________Wt- ______________ HL- ____________

 

Primary Care Doctor Assigned To - _______________________________

 

Specialist Referral to - __________________________________________

 

 

Comments / Notes

 

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419 He Fang Street Hang Street, Hangzhou
086-0571-87780120

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