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沃勒医生初诊问卷

2015-2-25 19:51| 发布者: admin| 查看: 1589| 评论: 0

摘要: Dr. Woeller China Health Questionnaire 沃勒医生中国咨询问卷 Initial(初诊) 如何填写(How to fill out appropriate) 例子 EXAMPLE X Within 30mins(30分钟以内) Often 经常 X Sometime ...

Dr. Woeller China Health Questionnaire

沃勒医生中国咨询问卷

Initial(初诊)

如何填写(How to fill out appropriate

例子 EXAMPLE

X

Within 30mins30分钟以内)

 

Often 经常

X

Sometime 有时

 

Seldom 从不

请复制“X”,然后将其粘帖至下面的表格中。

 

Please do NOT add any question inside the questionnaire, submit your question only in the question section below. Please list the brand of current supplement and medication in English, do NOT use abbreviation and inform nick name.

请勿在问卷中提出任何问题,所有问题请在最后的问题框中提交。所有正在服用的补充剂和药物,请列出其英文品牌名称,勿用缩写或其它非正式名称。

 

特殊儿童一点通订单号(Order Number

 

电子邮件地址(Email Address

 

病人姓名(Name of patient:

请用汉语拼音填写(张三 Zhang San

姓(Last Name): 

名(First Name):

病人性别(Sex of patient:

 

Male

 

Female

病人年龄(Age of patient:

 

岁(Year

 

月(Month

Can child swallow capsules or tablets?

孩子是否能吞服胶囊或药片?

 

YES

 

 NO

Have your child potty trained?

请问孩子是否能自行上厕所?

 

YES

 

 NO

What age where developmental problems first recognized?

何时开始意识到孩子出现问题的?

 

小于三个月(less than 3 months

 

三个月(3 months

 

六个月(6 months

 

一岁(1 Year

 

两岁(2 Years

 

大于两岁(Greater than 2 years)

 

 

Developmental History

病史调查

1st year development (normal, problems, concerns)

第一年的情况(正常、有问题还是有点疑问)

 

正常(Normal

 

有问题(Problem

 

有点担心(Concerns

Brief description(简述情况,不超过50字)

 

2nd year development (normal, problems, concerns)

第二年的情况(正常、有问题还是有点疑问)

 

正常(Normal

 

有问题(Problem

 

有点担心(Concerns

Brief description(简述情况,不超过50字)

 

 

Medical Problems (allergies, ear infections, heart, lungs, digestive issues, etc.):

病症信息(过敏、耳部感染、心肺问题或消化道问题等):

 

过敏(Allergies)                  

 

耳部感染(Ear Inlfection                          

 

心肺问题(Heart & Lungs                                    

 

消化问题= Degisting Problem                                   

Digestion Concerns(消化道问题)

 

Constipation (便秘)

 

Sometimes有时

 

Often 经常

 

Always 总是

If the patient has constipation, please describe:

如果病人存在便秘问题,请选择是以下哪种情形:

 

Urge to go, but cannot pass the stool. 想解大便,但是拉不出来。

 

Urge to go, but withhold the stool. 想解大便,但是又忍着不拉出来。

 

No sensation to go. 根本不想解大便。

 

Diarrhea (腹泻)                              

 

Sometimes有时

 

Often 经常

 

Always 总是

                                    

Foul Gas


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