Questionnaire for health check-up (설문지)
Registration Date:
Name / Family: Given: Middle:Date of Birth / (dd) (mm) (yy) / Age :
Nationality / Gender:□ Male □ Female
Status / □ Resident □ Tourist □ Other ( )
Address (Korea) / Home Address:
Company:
Contact Number (In Korea) :
- Mobile number:
- Telephone number: (Home) (Office)
Alien Registration number:
Permanent Address
(Outside Korea)
Please, choose the way you would like to have your stomach examined. (위검사선택)
Please check <√>
□ Photography (위장촬영) □ Endoscopy (위내시경)
* If you want to be put to sleep for the endoscopy, please make an appointment before the date of the health check-up. (수면내시경, 사전예약)
Please, choose the way you would like to be notified of the results. (판정선택)
Please check <√>
□ Visiting the hospital (방문) □ By Mail (post) (우편발송)
What are your reasons for taking this medical exam? (검진동기) Please check <√>
□ Illness □ Group testing by company □ Family’s suggestion
□ Regular medical exam □ Others:
These are questions about your medical history. (과거병력) Please check <√>
- Have you ever been diagnosed with high blood pressure: □ No or □ Yes (When: )
- Have you ever been diagnosed with diabetes: □ No or □ Yes (When: )
- Have you ever been diagnosed with pulmonary tuberculosis: □ No or □ Yes (When: )
Have you ever been diagnosed with any of the following diseases by a medical doctor?
It you have, please check<√>
□ Cancer
□ Gastritis/ Duodenitis
□ Gastric ulcer/ Duodenal ulcer
□ Hepatitis B carrier
□ Hepatitis C
□ Disorder of Liver, functional
□ Fatty liver
□ Hyperlipidemia
□ Gallbladder stone
□ Polyp- rectal, colon
□ Asthma
□ Others (writes):
Have you ever had surgery? □ Yes or □ No (수술경험)
If you have, please specify what type.
The type of surgery:
When:
Are you presently taking any medications? (복용하는 약)
□ No □ Yes (The name of the medication):
Do you have any family members who have suffered from cancer, diabetes, heart disease, etc?
If you have, Please check <√> and write the relation with you. (가족력)
Disease / Relation / Disease / Relation□ Hypertension / □ Cancer
□ Tuberculosis / □ Asthma
□ Diabetes / □ Congenital heart disease
□ Stroke / □ Rheumatoid
□ Chronic hepatitis / □ Allergy
□ Liver cirrhosis / □ Colon disease
□ Others:
If you have recently had any symptoms listed below, please check<√>
Sudden change in weight
□ Weight loss:______kg for (duration) ______
□ Weight gain:______kg for (duration)______
Digestive system
□ Indigestion (소화불량)
□ Burping (belching) (트름)
□ Pain in the chest (명치나 가슴통증)
□ Feel abdominal swelling (bloating) (배가 더부룩함)
□ Heartburn (fasting, after eating)속쓰림
□ Nausea, Vomiting (구역질, 구토증상)
□ Uncomfortable feeling in the throat (목의 이물감)
□ Stomachache (복통)
□ Pain in the right upper abdomen(우상복부 통증)
□ Diarrhea (설사)
□ Bloating, have gas(복부/가스팽만)
□ Constipation(변비)
□ Defecate frequently (잦은 배변)
□ Thin stools(변이 가늘다)
□ Bloody stools(혈변) □ Black stools(검은변)
Endocrine system
□ Thirsty, Urinate a lot(갈증, 소변양의 증가)
□ Anxiousness, Nervousness, Depression(불안, 초조, 우울)
□ Backache(허리가 아픔)
□ Hot flashes, Facial flashes(얼굴이 화끈거리고 달아오름)
□ Palpitation, Sweating(가슴이 뛰고 땀이 남)
Urinary system
□ Difficulty urinating(소변보기 힘들고 잔뇨감)
□ Cloudy urine(소변색 탁함)
□ Pain in the side of the lower abdomen(옆구리아랫배 통증)
□ Frequent night urination(야간에 잦은 소변)
□ Trouble holding urine(소변을 못 참음)
□ Blood in the urine(혈뇨)
□ Incontinence(요실금)
Others
□ Itchy skin(피부가려움증)
□ Hives(두드러기)
□ Poor vision(시력저하)
□ Pain in the eyes(눈이 아픔)
□ Hard of hearing (청력감소)
□ Ringing in the ears (tinnitus) (이명)
□ Ear discharge(귀 분비물)
□ Hoarseness(목소리가 자주 쉼)
□ Dizziness(어지러움)
□ Frequent nosebleeds(코피 잘남)
□ Sharp pains in the joints, ache all over (뼈마디 쑤시고 아픔)
□ Joint movement disorder (관절운동 장애)
□ Bruise easily(멍이 잘 듬)
□ Gums bleeding(잇몸에서 피가 남)
□ Bad breath(구취)
□ Toothache(치통)
What is your occupation?
What is your martial status?
Please note anything specific that you would like to speak to a physician about:
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