PART 1: HEALTH DECLARATION Nationality: Name: (Last) (First) (M. Initial) Gender: Date of Birth: Y/ M/ D/ Male□ Female□ Health History: Have you ever suffered any of the following conditions? Please mark X in appropriate box Psychiatric illness Thyroid Diseases □ □ □ □ Epilepsy Kidney Diseases □ □ □ □ Migraine Cancer □ □ □ □ Asthma HIV/AIDS □ □ □ □ Tuberculosis (PTB) Venereal Diseases □ □ □ □ Hypertension (HPT) Leukemia □ □ □ □ Diabetes Mellitus (DM) Hemophilia □ □ □ □ Heart Diseases Hepatitis □ □ □ □ Malaria Measles □ □ □ □ German Measles (rubella) □ □ Please State (if any) Other illnesses ………………………………………………………………………………………………………. Operation / Surgical ………………………………………………………………………………………………………. Allergic to ………………………………………………………………………………………………………. Family Medical History (if any) Father:…………………………………………… Mother: …………………………………………… Past Year Life: Please select 1. 8 hours from insomnia Sleep: □7~8 hours every day □Under 7~ □Often suffer 2. If that is basic to exercise each time for 30 minutes and 3 times every week at least, did you achieve? □No □Yes 4. Do you often feel anxious and or not worried? □Few □Sometimes □Often 5. Do you often feel the chest is stuffy? □No □Sometimes □Yes 6. Stomach-ache? □No □Sometimes □Often;. Headache? □No □Sometimes □Often 7. The menarche (girl only): (1) The age of the menarche: ______years-old (2) Is menstrual cycle regular? of partition ______day) □No □Yes(Date (3) Do you ever have menstrual cramp phenomenon □No □Yes
PART 1: HEALTH DECLARATION Nationality: Name: (Last) (First) (M. Initial) Gender: Male□ Female□ Date of Birth: Y/ M/ D/ Health History: Have you ever suffered any of the following conditions? Please mark X in appropriate box Psychiatric illness Epilepsy Migraine Asthma Tuberculosis (PTB) Hypertension (HPT) Diabetes Mellitus (DM) Heart Diseases Malaria □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Thyroid Diseases Kidney Diseases Cancer HIV/AIDS Venereal Diseases Leukemia Hemophilia Hepatitis Measles German Measles (rubella) □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Please State (if any) Other illnesses ………………………………………………………………………………………………………. Operation / Surgical ………………………………………………………………………………………………………. Allergic to ………………………………………………………………………………………………………. Family Medical History (if any) Father:…………………………………………… Mother: …………………………………………… Past Year Life: Please select 1. Sleep: □7~8 hours every day □Under 7~ 8 hours □Often suffer from insomnia 2. If that is basic to exercise each time for 30 minutes and 3 times every week at least, did you achieve? □No □Yes 4. Do you often feel anxious and worried? □Few or not □Sometimes □Often 5. Do you often feel the chest is stuffy? □No □Sometimes □Yes 6. Stomach-ache? □No □Sometimes □Often;. Headache? □No □Sometimes □Often 7. The menarche (girl only): (1) The age of the menarche: ______years-old (2) Is menstrual cycle regular? □No □Yes(Date of partition ______day) (3) Do you ever have menstrual cramp phenomenon □No □Yes
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