Central Office
Patient's Medical History
Personal Information 個人資料
Patient's Name 病人姓名*
Date of Birth 出生日期*
Gender 性別*
-- Please Select 請選擇 --
Male 男
Female 女
HKID Number 身分證號碼*
Body Weight 體重 (KG 公斤)*
Temperature 體溫 (ºC)*
Blood Pressure 血壓 (mmHg)*
LAST MEAL TIME BEFORE THE PROCEDURE？上⼀次進餐時間*
Medical Record 醫療紀錄
請回答以下各項問題，若有請回答”是”，若沒有請回答”否”
Please answer Yes or No to the following questions.
YES 是
NO 否
你曾否接受過麻醉？
Have you had any anaesthetic before? 如有，屬於哪種？
全⾝麻醉 General Anaesthesia
硬膜外麻醉 Epidural Anaesthesia
監察麻醉 Monitored Anaesthesia Care
你有否在過去的⼿術或麻醉中出現問題？請列出 :
Have you had any problem with previous surgery with anaesthesia?
你的親屬曾對麻醉藥有不良反應嗎？
Has anyone in your family had problem with anaesthesia?
你有否對某些食物、藥物或其他東⻄有過敏反應？請列出 :
Do you have allergies to food, medicine or anything else ?
你有否定期 / 短期性服⽤任何藥物？請列出 :
Are you on any regular / short term medication?
你現在患有傷風或咳嗽嗎?
Are you suffering from a cough or cold at present?
你有否患有或曾經患有以下之疾病?
Are you suffering from, or have you ever had the following condition?
心臟病
Heart Problems
胸痛
Chest Pain
高血壓
High Blood Pressure
心跳急促
Palpitations
步⾏時喘氣
Shortness of Breath with walking
夜間喘氣
Waking up at night short of breath
偏頭痛
Migraine
哮喘
Asthma
肺氣腫
Emphysema
肺結核
Tuberculosis
其他肺部疾病
Other Lung Problems
流⾎難⽌或容易瘀腫
Excessive Bleeding or Bruising
肝炎、⿈疸或肝臟疾病
Hepatitis, Jaundice or liver Problems
⽀氣管炎
Bronchitis
甲狀腺疾病
Thyroid Problems
糖尿病
Diabetes
⾜踝⽔腫
Ankle Swelling
中風、⼿腳軟弱
Stroke, arm or leg weakness
眩暈
Fainting spells or dizziness
貧⾎
Anemia
精神病
Psychiatric illness
關節炎
Arthritis
潰瘍
Ulcer Problems
癲癇、抽搐
Epilepsy, Fits or Seizures
腎臟或膀胱疾病
Kidney or bladder problem
Others 其他
CONSENT 同意
Patient’s / parent’s / Guardian’s signature 病人簽署 / 病人的父母或監護人簽署*
Guardian's Name
監護人姓名
