Name: 姓名:
Contact Number: 联络号码:
Email: 电邮:
1) Does your tailbone pain affect your ability to sit for more than 20 minutes? 您的尾骨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
2) Is your tailbone pain aggravated by prolong walking for more than 20 minutes? 您的尾骨疼痛是否会因超过20分钟的长时间步行而变得更糟吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
3) Does coughing / sneezing make your tailbone pain worse? 咳嗽或打喷嚏会加重尾骨的疼痛吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
4) Does passing of motion aggravate tailbone pain? 排便时会加重尾骨的疼痛吗？ Never 不曾Seldom 不常Sometimes 有时Often 经常Always 一直
5) Does your tailbone pain affect your frequency of sexual intercourse? 您的尾骨疼痛会影响您的性交频率吗？ 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
Δ
