Name: 姓名:
Contact Number: 联络号码:
Email: 电邮:
1) Where does your chest pain radiate to? 您的胸痛蔓延至身体的哪个部位？
2) Is your chest pain accompanied by shortness of breath? 您的胸痛是否会出现呼吸急促的情况？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
3) Is your chest pain accompanied with dizziness? 您的胸痛是否会出现头晕的症状？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
4) Is your chest pain accompanied with increased sweating? 您的胸痛是否会导致出汗量增加？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
5) Is your chest pain worse during/after exercise? 当您正在进行运动或运动完毕后，胸痛是否会变得更糟？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
6) Is your chest pain present during rest? 当您处于休息状态是否也会出现胸痛情况？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
7) Any recent falls that may have hurt your chest or upper back? 您最近是否有跌倒并伤到您的胸部或上背？ Yes 是No 否
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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