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.)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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