Name: 姓名:
Contact Number: 联络号码:
Email: 电邮:
1) Does the pain affect your stomach and intestinal function (e.g. Digestion & bowel habits)? 疼痛会影响您的胃和肠道的功能吗 (例如消化功能和排便习惯）？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
2) Do you have abdominal pain before / after meals? 用餐前或用餐后您会感觉腹部疼痛吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
3) Do you have abdominal pain before / after meals? 用餐前或用餐后您会感觉腹部疼痛吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
4) Do you experience frequent nausea or vomiting? 您是否经常会恶心反胃或想呕吐？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
5) Which bowel habits best describe you? 以下哪些描述与您的排便习惯相符？ Constipation 便秘Diarrhea 腹泻More constipated and less diarrhea 经常便秘但少腹泻More diarrhea and less constipated 经常腹泻但少便秘Normal 一切正常
6) Do you experience any difficulty or pain during urination? 您是否面对任何排尿困难或排尿时感到疼痛？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
7) Do you wake up from sleep due to abdominal or pelvic pain? 您是否因腹部疼痛或骨盆疼痛而从睡梦中苏醒？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
8) Does the pain affect your ability to sit longer than 20 minutes? 疼痛会造成您无法久坐超过20分钟吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
9) Does the pain affect your ability to perform and function normally at home/work/school? 疼痛是否会影响您在于日常生活，工作上或课业上的运作能力？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
10) Does the pain affect your ability to take part in physical activity? (e.g jogging, yoga, cycling, etc.) 疼痛会影响您参与任何体力活动和锻练吗？(例如跑步，瑜伽，骑自行车等）? Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
11) Does the pain affect your ability to wear certain clothes? (e.g. underwear, tight fitting clothes) 疼痛是否会影响您穿上某些衣物？(例如：内衣裤，紧身衣服等） Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
Thank you for completing this questionnaire to let us better understand your pain. 感谢您回答此疼痛问卷，让我们更了解您的疼痛状况。 We respect and keep your data safe. 我们尊重并保证您的个人资料安全。
In accordance with the Personal Data Protection Act (PDPA) of Singapore, 根据新加坡个人资料保护法 （PDPA), *
I consent to the sharing of my medical records within Singapore Paincare Center as well as other healthcare providers for any investigations, treatments and other healthcare purposes if necessary. (E.g. Hospitals, Imaging Centers, Physiotherapy Centers, etc.)我同意与新加坡疼痛护理中心以及其他医疗保健提供者共享我的医疗记录，以便在必要时进行任何检查，治疗或用于其他医疗保健的目的。(例如：医院，扫描中心，物理治疗中心等 Please refer to our privacy policy: https://www.paincarecenter.com.sg/privacy-statement.
I consent to receive marketing updates and educational information from Singapore Paincare Center.我同意接收新加坡疼痛护理中心的营销材料，包括相关活动的更新动态和教育信息
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