CONFIDENTIAL保密-安美癌科治疗中心.DOCVIP

CONFIDENTIAL 保密 RISK ASSESSMENT / EARLY DETECTION QUESTIONNAIRE 風險評估 / 預早偵測 問卷 Please complete this questionnaire truthfully and to the best of your ability. This will help your doctor to evaluate your cancer risk and early detection of cancer. 請盡閣下所知而據實填寫此問卷, 此有助醫生評估閣下之癌症風險及預早偵測癌病 ? Name 姓名 _____________________________________ Sex 性別 __________________________ Date of Birth 出生日期 (d日/m月/y年) ___________________________ Age 年齡 _____________ HKID No. 身份證號碼 ________________________________________________________________ Telephone No. 電話號碼____________________ Fax No. 傳真號碼 _________________________ Home Address 住址 __________________________________________________________________ __________________________________________________________________ Name and telephone no. of spouse or next of kin (for doctor’s record) 配偶或近親家屬的姓名及電話號碼 (醫生需作記錄) Name 姓名 _______________________________ Telephone No. 電話號碼 __________________________ Name and telephone no. of family doctor 家庭醫生的姓名及電話號碼 Name 姓名 _______________________________ Telephone No. 電話號碼 __________________________ Ethnicity 種族 □ Asian 亞洲人 □ Black or African-American □ American Indian/Alaskan Native □ Native Hawaiian or Pacific Islander □ White 白種人 □ Hispanic/Latino 西班牙人/拉丁美洲人 □ Jewish 猶太人 Your Height and Weight 閣下的身高及體重 What is your height (in feets/inches)? 你的身高 (尺/寸)? _______________ What is your weight (in pounds)? 你的體重 (磅)? _______________ How much did you weight when you was new born (in pounds)? 你出生時候的體重 (磅)? _______________ How much did you weight at age 18 (in pounds)? 你十八歲時候的體重 (磅)? _______________ Your Family History 閣下的家族史 Has any member of your immediate family (parents, grandparents, uncles and aunties, brothers and sisters, children, first degree cousin) ever been diagnosed with cancer? 閣下之直系家屬(父母, 祖父母, 叔嬸, 兄弟姊妹, 子女, 近親表兄弟表姊妹) 曾否診斷為患癌病?