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Name*
:
Email*
:
Address*
:
Gender*
:
Male
Female
Blood Group*
:
Ethnic Group*
:
Date of Birth*
:
/
/
(eg: 31 / 01 / 2007)
Marital Status*
:
Nationality*
:
Occupation*
:
Tel. *
:
-
Fax
-
Mobile
:
-
Have you ever consulted a TCM doctor before
(if any)
:
Lifestyle habits*
:
Drinking
Yes
No
Smoking
Yes
No
Health history
Asthma
Convulsions
Heart trouble
High cholesterol
Cancer
Diabetes
Kidney disease
High blood pressure
Hemophilia
Organ transplant
Others,
please specify
Date of most recent physical
check
:
/
/
(eg 31 / 01 / 2007)
Health Insurance Provider
:
Reason for choosing this clinic
:
