Headache Questionnaire (Eng + Mandarin)

Name:
姓名:

Contact Number:
联络号码:

Email:
电邮:

1) Is there a family history of headaches?
您是否拥有任何家族遗传性头痛？
Yes 是No 否

2) Did you suffer from frequent headaches when you were younger?
您是从什么时候频繁的开始头痛呢？
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

3) Does your headache start after an accident/ illness/ infection?
您的头痛是在任何意外，疾病或感染后开始的吗？
Yes 是No 否

4) If yes, what was the incident?
如果是，请问是什么事件？

5) Are there any other associated symptoms with your headache such as:
以下的症状是否有与您的头痛相符:
Light Sensitivity 光敏感度Nausea 反胃Ringing of Ears 耳鸣Dizziness 头晕Others 其他None 没有任何

Others

6) What is your current level of stress?
您目前的压力是处于什么程度？
Nil 否Low 低Moderate 中等High 高Severe 严重

7) Do you take work/school leave due to your headaches?
您是否因头痛而请假？
Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直

8) Is your headache associated with the weakness of your hands and legs?
您的头痛会导致您的手脚无力吗?
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.)Please refer to our privacy-statement.
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)。请查阅我们的隐私保护政策。
 

I understand that I may withdraw my consent for such communications at any time by notifying the Clinic in writing, and that such withdrawal will not affect my access to medical care.[The communications referred to above may constitute advertisements for healthcare services within the meaning of the Healthcare Services Act 2020. By signing this form, you consent to receiving such communications pursuant to Regulation 6(4) of the Healthcare Services (Advertisement) Regulations 2021. Your personal data will be handled in accordance with the Personal Data Protection Act 2012 (Singapore).]
本人理解，本人可随时以书面方式通知本诊所撤回此类通讯同意，且此撤回不会影响本人继续获得医疗护理服务的权利。
[上述通讯可能构成《2020年医疗服务法》(Healthcare Services Act 2020) 所指的医疗服务广告。签署本表格即表示本人同意根据《2021年医疗服务(广告)条例》(Healthcare Services (Advertisement) Regulations 2021)第6(4)条接收此类通讯。本人的个人资料将依据《2012年个人资料保护法》(新加坡)(Personal Data Protection Act 2012 (Singapore)) 妥善处理及保护。]
 

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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