不是中藥 itsherbs.com Patient Registration · 患者登记

Medical Form 医疗信息表

请如实填写以下资料，完成后在页面底部电子签名并提交，资料会直接送到诊所系统。
Please complete the form, sign at the bottom and submit. Your details go straight to the clinic.

1填写资料Fill in 2电子签名E-sign 3提交Submit
A

Patient Information个人资料

Gender性别*
请选择性别 · Required
Preferred Language沟通语言（可多选）*
请至少选一种语言 · Please pick at least one
B

Medical History病史

Have you been hospitalized recently?您近一年里是否有入院？*
请选择 · Required
Do you have the following conditions?您是否具备以下条件？*
请勾选，没有的话选「以上皆无」 · Pick at least one or "None"
Do you have any drug or food allergies?您是否有对药物 / 食物过敏？*
请选择 · Required
Do you have a history of cancer?您是否有癌症 / 癌症病史？*
请选择 · Required
Others (please state)其他（请写明）
C

Medications & Diet用药与饮食

Are you regularly taking any of the following medications?您是否定期服用以下指示的药物？*
请勾选，没有的话选「没有服用」 · Pick at least one or "None"
Are you taking any supplements?您是否有服用保健品？*
请选择 · Required
Are you a Vegetarian?请问您是素食者吗？*
请选择 · Required
D

Consent & Signature同意与签名

请勾选确认 · Please tick to confirm
Signature签名*
请在此签名 · Sign here
Date 日期：
请先签名 · Signature required

提交后资料会加密送到不是中藥 itsherbs.com 诊所系统，仅供医疗团队使用。
Your details are sent securely to the clinic and used by the medical team only.

✓

已提交，谢谢Submitted, thank you

您的资料已送到诊所系统。请把设备交回柜台，我们的团队会为您安排下一步。
Your form has been received. Please hand the device back to the counter.