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Questionnaire
病人资料/Patient information
基础资料/Personal Profile
性别/Gender
A.男/Male
B.女/Female
出生日期/Date of birth
联系地址/Current Address
请详细填写目前居住地址、城市,邮编/
联系电话/Telephone
请用划线“-”对号码进行分隔,如:000-000-0000/
请写出您预约的日期及时间。例如2022年8月30日下午3点/Please write down your appointment date/time. Ex: 08/30/2022 3:00PM
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 US Health Care Providers
A.是/Yes
B.否/No
C.不知道/I don't know
从哪里了解到的信凯尔(本题可多选)/How did you hear about SinCare?
A.华人资讯网/Chinese news
B.YouTube直播/YouTube
C.微信公众号/WeChat Official Account
D.百度搜索/Baidu
E.谷歌Google搜索/Google
F.登机牌广告/Boarding pass
G.其他 - 请在下题中填写/Other - Please specify in the next question
从哪里了解到信凯尔 - 其他/How did you hear about Sincare - Others
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
您预约的原因是什么 - 全科/What is the reason for your visit:
A.年度体检/Annual Physical
B.哮喘/Asthma
C.过敏/Allergy
D.复查/Follow up on previous visit
E.跟进近期住院情况/Follow up on recent hospitalization
F.生病/Illness
G.受伤/Injury
H.身体疼痛/Pain
J.睡眠问题/Sleep problem
K.老年综合/Geriatrics
L.紧急护理/Urgent Care
M.其他 - 全科/Other - Primary
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。如果没有详细信用卡信息,医生不会接受预约的请求。/
A.自付信用卡/Self Pay: Credit Card
B.保险支付/Insurance
持卡人姓名/Cardholder’s Name
填写信用卡上的名字(英文拼写)/
信用卡卡号/Card Number
请依照卡片上的号码格式填写,每4码后空一格,如:0000 0000 0000 0000/
信用卡有效期/Expiration Date
或VALID THRU,见信用卡卡面,如04/27/
校验码/Security Code
请填写信用卡背面签字栏的3或4位数校验码/
信用卡注册地址/Card Registered Address
请详细填写信用卡注册地址,包括邮编,街道名,城市/
持卡人电话/Phone number
请用划线“-”对号码进行分隔,如:000-000-0000/
保险信息/Insurance Information
请拍下您的保险卡正面信息/Insurance card: Front
Upload
请拍下您的保险卡背面照片/Insurance card: Back
Upload
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