Name: 姓名:
Contact Number: 联络号码:
Email: 电邮:
1) Did you suffer from facial pain when you were younger? 您是从什么时候开始患有脸部疼痛呢? As a child 年幼期As a teenager 少年期In my 20’s-40’s 20-40岁左右In my 50’s-60’s 50-60岁左右
2) Does your facial pain started after an accident/ illness/ infection? 您的脸部疼痛是在任何事故，疾病或感染后开始的吗？ Yes 是No 否
3) If yes, what was the incident? 如果是，请问是什么事件？
4) Does your facial pain affect your ability to eat / chew / drink? 您的脸部疼痛是否会影响您进食，咀嚼或饮用的能力？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
5) Does your facial pain limit the opening of your mouth / movement of your jaws? 您的脸部疼痛是否限制您张嘴或活动下巴？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
6) Is your facial pain triggered by speech? 您的脸部疼痛是由言语引起的吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
7) Does your facial pain affect your appetite? 您的脸部疼痛会影响您的食欲吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
8) Is your facial pain triggered by light touching on the skin of your face or by brushing teeth? 您的您的脸部疼痛是否会因轻轻的触碰或刷牙而引起？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
9) Is your facial pain associated with weakness of the hands and legs? 您的脸部疼痛会导致您的手脚无力吗？ 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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