Medical Examination Form 身体检查报告书 - 郑德炎日间复康护理中心.PDF

香港復康會 The Hong Kong Society For Rehabilitation 鄭德炎日間復康護理中心 Cheng Tak Yim Day Rehabilitation Care Centre 九龍藍田復康徑七號地下十七室 TEL:2816 0899 FAX:2872 4722 Medical Examination Form 身體檢查報告書 Part I Particulars of Applicant 甲部 申請人資料 Name Sex Age 姓名:___________________ 性別:___________________ 年齡:___________________ HKIC NO. Hospital/Clinic Ref. No. 身份證號碼:_____________ 醫院/診所檔號:___________________________________ Part II History of Major Illnesses 乙部 病歷記錄 (1) Any history of major illnesses/operations? Yes □ No □ 曾否患有何種疾病/曾否接受何種大型手術? 有 無 If yes, please specify the diagnosis 如有，請註明診斷:__________________________________________________ (2) Any evidence of infectious or contagious disease? Yes □ No □ 有否患有傳染病? 有 無 If yes, please specify 如有，請註明:______________________________________________________ (3) Past psychiatric history, if any, including the diagnosis, period and whether regular following treatment is required. 如過往有精神病記錄，請詳述病歷及是否需要定期覆診。 ___________________________________________________________________ (4) Detail of present medication, if any. 如目前須服用藥物，請詳述藥名及服用量。 ___________________________________________________________________ (5) Any history of allergy to medicine, food or others? Yes □ No □ 有否對藥物 、食物或其他過敏? 有 無 If yes, please specify 如有，請註明:_________________________