铭传大学学生健康资料表-铭传大学应用英语学系.DOCVIP

銘傳大學學生健康資料表 MCU Students Medical Examination Report 銘傳學號 MCU Student ID no. 身分證號 ID no. : 護照 Passport no. : 血型 Blood type 姓名 Name □男 male □女 female 出生日期 Date of birth (yy /mm /dd) 系所 Department 年 班 Grade Class 緊急聯絡人 Emergency contact person 聯絡人電話 Phone no. 關係 Relationship 本人住址 Address 行動電話 Cell phone no. E-mail 健康基本資料 ※個人病史:勾選本人曾患的疾病。Please check if you have medical history of： □1.無None □2.肺結核Tuberculosis □3.心臟病Heart disease □4.肝炎Hepatitis □5.氣喘Asthma □6.腎臟病Nephralgia □7.癲癇Epilepsy □8.紅斑性狼瘡SLE □9.血友病Hemophilia □10.蠶豆症G6PD deficiency □11.關節炎Arthritis □12.糖尿病Diabetes Mellitus □13.心理或精神疾病 Mental or psychological disease: □14.癌症: Cancer □15.海洋性貧血 Thalassemia □16.重大手術Any major surgery: □17.過敏物質名稱: Allergic to: □18.其他Anything else: 特殊疾病現況或應注意事項 □詳如病歷摘要 女性請填寫:本人確定無懷孕，接受X光檢查 Females, please confirm you are not currently pregnant to have an x-ray □同意Agree □不同意 Disagree 領有重大傷病證明卡，類別 參加保險，類別□全民健保□學生團體保險□其他 Have major illness certificate, type______________. Insurance type: □National Health Insurance □Student Group Insurance □Other 領有身心障礙手冊，類別 等級:□極重度□重度□中度□輕度 Have physical disabilities handbook, type________________. Level: □Extreme □Severe □Moderate □Mild 若有左述特殊疾病尚未痊癒或仍在治療中，可提供就診病歷摘要(含疾病現況及應注意事項)，做為照護參考。 If you are presently suffering from any of the abovementioned conditions and are currently under treatment, related medical records (including current status and medical alert notices) may be provided as reference. 家族疾病史:患有重大遺傳性疾病之家屬稱謂 ，疾病名稱 Family medical history: Which, if any, of your family members have hereditary medical conditions/illness?___________________ Condition/illness? _________________ 過去一年生活回顧 Choose the most appropriate answer applicable to you in the post one year： ※請勾選最適合的選項：Please check 1.睡眠習慣： □每日睡足7~8小時 □不足7~8小時 □時常失眠 How many hours do you sleep a day？□7~8 hours or more □less than 7~8 hours □I have sleeping disorder (insomnia) 2.早餐習慣： □每天吃□偶爾□不吃 Do you have breakfast？□Eve