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沃勒医生复诊问卷

2015-2-25 19:52| 发布者: admin| 查看: 577| 评论: 0

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

Dr. Woeller China Health Questionnaire

沃勒医生中国咨询问卷

Follow-up (复诊)

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。

 

订单号(Order Number

 

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

 

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)

 

Diarrhea (腹泻)                              

                                    

Foul Gas (放臭屁)

Vaccine Regression (did child health and behavior change after vaccines):

疫苗问题(孩子是否在注射过疫苗后出现症状):

 

YES

 

NO

Sleeping Problem

睡眠问题

Need how long to fall asleep?(需要多久才能入睡?)

 

Within 30mins30分钟以内)

 

Often 经常

 

Sometime 有时

 

Seldom 从不

 

30-60mins3060分钟)

 

Often 经常

 

Sometime 有时

 

Seldom 从不

 

Over 60 mins(大于60分钟)

 

Often 经常

 

Sometime 有时

 

Seldom 从不

Does the patient wake up during the night? (半夜会醒来吗?)

 

Often 经常

 

Sometime 有时

 

Seldom 从不

Does the patient wake up in the early morning? (大清早就醒来吗?)

 

Often 经常

 

Sometime 有时

 

Seldom 从不

Allergies to medications or supplements?

是否对药物或营养补充剂过敏?

 

YES

 

NO

If “Yes”, please list the allergic items below:

如果选,请将过敏物质填入下表

 

 

 

 

Current Medications and/or supplements:

目前正在使用的药物或补充剂:

 

Multi-Vitamin(复合维生素)                            

 

Vitamin B6(维生素B6                            

 

Methyl B12(甲基B12                            


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