信凯尔-美国专家智能预约平台

病人资料/Patient Information

基础资料/Personal Profile

姓名/Name
请填写英文拼音填写，名在前，姓在后。如张三为“San Zhang”/

性别/Gender

A.男/Male B.女/Female

出生年月日/Date of birth

联系地址/Contact address
请详细填写目前居住地址、城市，邮编/Please enter detailed address including city, zip code

联系电话/Contact phone number
请用划线“-”对号码进行分隔，如：000-000-0000 或是 +86 13600000000/Please follow the format: 000-000-0000 or +86 13600000000

邮箱/Email address

微信账号/WeChat account

婚姻状况/Marital Status

A.已婚/Married B.单身/Single C.离异/Divorced D.分居/Separated E.丧偶/Widowed

是否有美国医院接受的医院保险/Do you have insurance accepted by the US healthcare providers?

A.是/Yes B.否/No C.不知道/Don't know

是否需要翻译？/Do you need an interpreter?

A.是/Yes B.否/No

从哪里了解到信凯尔 - 其他/How did you hear about Sincare?

你的留言（填写时请勿空格，请勿分段落）/Your messages (Do not space out and break into paragraphs when describing)

病史/Medical History

基础病史/General Medical History

既往病史（可多选）/Medical History

A.高血压/Hypertension B.糖尿病/Diabetes C.心血管疾病/Cardiovascular D.癌症/Cancer E.肾病/Kidney Problem F.慢性阻塞性肺病/COPD G.免疫系统疾病/Immuno H.其他/Other

列出正服用的处方药的药名与功效（填写时请勿空格，请勿分段落）/Medication list (Do not space out and break into paragraphs when describing)
请填写：药名____功效____ 剂量____ 如何服用____,没有则不填。例：服用硝苯地平—用于降血压/

全科基础问卷/Primary Care

例行检查项目/Routine check up

A.开药/Medication Refill B.血检/Blood Work C.其他/Others

你准备复查哪些检查？/Follow up on previous visit:

A.复查血压/Recheck blood pressure B.复查血糖/Recheck blood sugar C.调整用药或开药/Adjust medication or refill D.血检/Blood work E.其他 - 复查/Other - Follow up

请填写你需要复查的其他项目/Please lists follow up items

请填写你有哪些生病症状（填写时请勿空格，请勿分段落）/Illness description (Do not space out and break into paragraphs when describing)

请描述受伤部位/Injury description

哪里疼痛？/Pain

A.头痛/Headache B.背疼/Back pain C.腹痛/Abdominal pain D.身体疼痛/Body ache E.关节炎/Arthritis F.其他/Others

老年综合科项目/Geriatrics

A.帕金森综合症/Parkinson's disease B.老年失智/Dementia C.其他 - 老年/Other - Geriatrics

请填写你需要就诊的其他老年综合科项目/Please describe other reasons for your Geriatrics visit

紧急护理项目 /Urgent care services

A.呼吸问题/Respiratory Issues B.受伤/Injury C.食物中毒/Food Poison D.过敏反应/起疹/Allergy/Rashes E.耳朵发炎/Ear Infection F.眼睛相关 - 疼痛，发炎等/Eye Related - Pain, Infection, etc.

请填写您就医的其他原因 - 全科/Other reasons for this appointment - Primary Care

账单支付信息/Payment Information

支付信息/Payment

选择医疗账单支付方式/Payment Type
如无保险请填信用卡信息以加快预约。若暂时不希望提供信用卡信息，填0。/

A.自付信用卡/Self Pay; Credit Card B.保险支付/Insurance

保险信息/Insurance Information

请拍下您的保险卡正面信息//

请拍下您的保险卡背面照片//