HUMANET PORTAL

의료 정보 양식.

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소개

원격 진료를 포함한 양질의 건강 표준 서비스를 위해 사용자는 그들의 건강 및 의료 상태에 대한 정확한 정보를 제공하고 정기적으로 업데이트하십시오. 우수하고 효과적인 건강 및 의료 서비스를 제공하기 위해 정보를 제공합니다.

이를 위해 귀하의 건강에 대한 세부 정보를 제공하도록 요청합니다. 필요하시면 연락드리겠습니다 자세한 내용을 확인하고 필요한 경우 의료 또는 치과 제공자에게 보고서를 요청하십시오. 가족력 또는 가족력이 있더라도 각 사용자의 건강은 개별적으로 고려됩니다. 전문적인 노출은 건강 상태 이면의 논리를 이해하는 데 지침이 될 수 있습니다.

유기 시스템별로 다음 10개 그룹의 질문에 모두 응답하십시오. 예라고 대답하면 모든 장기 시스템의 건강 문제에 대해 모든 질문에 대한 자세한 답변을 제공해야 합니다. 다른 잠재적인 건강 문제에 대한 공개 텍스트 외에 그룹 내에서 과소 질문 설문지에 명시되어 있습니다. 질문이 있는 경우 지원팀에 문의하여 조언을 받으세요. 당신은 귀하가 현재 다음과 같은 의료 서비스를 받았거나 받은 적이 있는지 여부를 표시하도록 요청받았습니다. 시스템과 기관에 의해 조직된 조건.

질문 중 하나라도 예에 체크한 경우 각 항목에 제공된 공간에 세부 정보를 기입하십시오 절. 이것은 Health Unit이 Yes의 중요성을 명확히 하는 데 도움이 될 것입니다. 대답. 단락과 함께 올바른 질문과 건강 상태를 인용했는지 확인하십시오. 문자와 포인트 번호. 의학적 상태에 대한 자세한 내용은 날짜를 포함하십시오. 질병/상태, 빈도, 기간, 어떤 치료를 받았으며 누구에게(예: 병원/ GP), 귀하가 아직 치료를 받고 있는지 여부 및 직장/학교 결석 기간(만약 적절한). 가족력(부모 또는 형제자매

이 설문지 끝에 있는 선언문에 서명해야 합니다. 귀하의 답변이 정확하고 정보를 숨기지 않는 것이 중요합니다.

계속하다

파트 A: 라이프스타일 및 일반 건강 관련 문제

일반적인 생활 방식 및 알려진 건강 문제

아래 질문에 예 또는 아니오로 답하십시오.

#	의문	예	아니
1	지난 6년간 비정상적인 체중 증가 또는 감소(20kg 이상)를 경험한 적이 있습니까? 개월?
2	지난 1년 동안 하루 평균 20개비 이상의 담배를 피우셨습니까?
3	귀하는 일주일에 술(맥주/와인/위스키 등)을 20잔(평균) 이상 마십니까?
4	마약, 마약, 풀 냄새를 맡았거나 마약 중독 치료를 받은 적이 있습니까?
5	HIV 또는 A-B 또는 C형 간염 진단을 받은 적이 있습니까?
6	부모/형제 중 암, 뇌졸중, 심장, 간 또는 신장을 앓은 사람이 있습니까? 질병?
7	당신은 현재 고통 받고 있습니까? 당뇨병, 고혈압 또는 고지혈증?
8	절단, 신부전, 혼수상태 등 당뇨병 관련 합병증이 있습니까?
9	Do you have dental issues involving your teeth, gums or cavities?
10	Do you wear any type of dentures (PUSTISO) removable or fixed?

11	너의 키?		cm/inch

12	Your Weight?		lbs/kg
#	Question	Yes	No
13	Are you taking medications regularly?
14	Are you currently attending a hospital/GP for treatment or waiting for an appointment?

If YES to any question or if any other General Health issues? Please Explain.

Your Answer

Please list below any of your Current prescribed medication including: tablets, capsules, injections, inhalers and creams including birth control? Please specify:

Your Answer

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PART B: CARDIO-VASCULAR SYSTEM RELATED HEALTH PROBLEMS

Do you have any Cardio-Vascular System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Chest pain
2	Angina
3	Heart Disease
4	Palpitations
5	Breathlessness
6	Varicose veins
7	Ankle swelling
8	Circulation problem
9	Rheumatic fever
10	Any blood disorder
11	Are using a pacemaker
12	Hypertension or Low blood pressure

If YES to any question or if any other Cardio-Vascular illness? Please Explain.

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PART C: RESPIRATORY SYSTEM RELATED HEALTH PROBLEMS

Do you have any Respiratory System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Asthma
2	Bronchitis
3	Pneumonia
4	Emphysema
5	Pleurisy
6	Pneumothorax
7	Tuberculosis
8	Cough
9	Hemoptysia
10	Epistaxis
11	Difficulty Breathing
12	Are you using Oxygen tank?

If YES to any question or if any other Lung or Respiratory disease? Please explain

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PART D: GASTRO-INTESTINAL SYSTEM RELATED HEALTH PROBLEMS

Do you have any Oral or Gastro-Intestinal System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Do you have Recurrent Dental, oral, Nausea, Dyspepsia or Dysphagia?
2	Do you have Recurrent Heartburn, Indigestion or Hiatus Hernia?
3	Gastric, Duodenal or Peptic ulcer?
4	Do you have Abdominal pain?
5	Diarrhea or Vomiting lasting more than one week?
6	Do you have any abdominal Hernia?
7	Gastro-intestinal or Rectal bleedings?
8	Irritable Bowel Syndromes?
9	Crohn’s Disease?
10	Ulcerative Colitis?
11	Jaundice or Problems with Gallbladder?
12	Any form of hepatitis or other liver problem?

If you answer YES or if you have any other Oral, Dental or abdominal complaint? Please explain

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PART E: AUTO-IMMUNE METABOLIC AND ENDOCRINE SYSTEMS RELATED HEALTH PROBLEMS

Do you have any Metabolic and Endocrine System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Any weight or appetite changes
2	Do you have Diabetes
3	Any Thyroid Disfunction
4	Any Adrenal Gland Disease
5	Do you have any auto-Immune illness related problems?

If you answer Yes or if you have Any other metabolic problems or other glandular disorder you are aware off ? Please explain.

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PART F: SKIN RELATED HEALTH PROBLEMS

Do you have any Metabolic and Endocrine System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Do you have any allergies or Urticaria?
2	Do you have Psoriasis?
3	Do you Have Eczema?
4	Do you have Allergic dermatitis?
5	Do you have any skin infections?
6	Do you have vetiligo?
7	Do you have tendency to skin cancer?
8	Do you have allopecia?

If you answer YES or if you have any other Oral, Dental or abdominal complaint? Please explain

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PART G: MUSCULOSKELETAL SYSTEM RELATED HEALTH PROBLEMS

Do you have any Musculoskeletal System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Do you have bones or joints pain, dislocation or swelling? If yes please indicate below.
2	Neck
3	Back
4	Shoulder
5	Elbow
6	Handled
7	Hip
8	Knee
9	Ankle
10	Have you been diagnosed as having arthritis, gout, or rheumatism?
11	Do you have Sciatica?
12	Do you have Osteoporosis or recurrent fractures?

If your answer is Yes to any question or if you have ever consulted an orthopedic surgeon, osteopath, Chiropractic, or physiotherapist? Please elaborate.

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PART H: NERVOUS SYSTEM RELATED HEALTH PROBLEM

Do you have any Psychology-Nervous System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Do you have headaches, migraines, vertigo, dizziness, giddiness or problems with balance?
2	Do you have any diseases of the nervous system like, neuritis, stroke or multiple sclerosis?
3	Did you had any Head injuries leading to loss of consciousness requiring hospital admission?
4	Do you have Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness?
5	Do you have any limb motor or sensory symptoms or loss of coordination?
6	Do you have any visual defect e.g., scotoma, blindness in one eye, night blindness, blindness, color blindness, reduced visual field, blurred vision or detached retina?
7	Do you have any eye disease or conditions such as glaucoma or retina issues?
8	Did you had any Injury or surgery to your eye(s) including laser eye surgery?
9	Do you have or had any Ear infection, discharge, tinnitus, a hearing defect including deafness?
10	Do you have issues with Speech and related functions like reading and writing skills and memory?
11	Do you have any defect in your testing and smelling abilities?

If you answer YES for any question or if you ever consulted an Otolaryngologist, Ophthalmologist.

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PART I: PSYCHOLOGY AND MENTAL HEALTH PROBLEMS

Do you have any Psychological or Mental Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Do you have Anxiety/Depression, phobias, mental breakdown or stress related problems?
2	Do you have any Mental Illness and / or cognitive disorders, such as: Alzheimer or Dementia?
3	Do you have any disorders affecting learning, memory, perception and problem solving?
4	Do you have any eating disorder e.g., anorexia nervosa or bulimia?
5	Do you suffer from Substance misuse?
6	Do you have sleeping disorder?

If YES to any question or if any other Lung or Respiratory disease? Please explain.

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PART J: GENITO-URINARY SYSTEM RELATED HEALTH PROBLEMS

Do you have any urinary System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
1	Frequency in urination
2	Pain with micturition
3	Urethral Discharge
4	Blood or change of urine color
5	Kidney stones
6	Urgency in Urination
7	Incontinence
8	Recurrent kidney or urinary tract infection
9	Cystitis
10	Urethritis

Any other kidney or bladder conditions or complaint? Please explain

Your Answer

NOTE: THAT IF THE USER GENDER IS SELECTED, THE USER WILL AUTOMATICALLY GO TO THE QUESTION ACCORDING TO THEIR GENDER.

Genitalia MEN:

Do you have any urinary System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
11	Any issues with the Prostate?
12	Any testicular issues?
13	Any actual or previous sexually transmitted infection?
14	Any sexuality issues, problems with erection etc.?

If YES or if any other genitalia or sexuality issues you are aware of? Please explain

Your Answer

Genitalia WOMEN:

Do you have any urinary System Health Problems?

Yes

Please answer the questions below with Yes or No

#	Question	Yes	No
11	Any problem with the menstruation?
12	Are you in Menopause phase?
13	Are you aware of, any breast lumps or disorder?
14	Any family members been diagnosed with breast cancer?
15	Are you aware of any disorder with ovaria or uterus: fibroid, cyste, polyps?
16	Any abnormal pap smear test?
17	Any complications during any of your pregnancies such as gestational?

If YES or if any other genitalia or sexuality issues you are aware of? Please explain

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