This treatment application is the first step in assisting the doctor in determining if you are a candidate for our non-surgical procedures and specialized treatment technology. Please answer the following questions honestly and to the best of your knowledge.
这份表格是在协助医生判断您是否适合接受我们的无手术与专业的治疗技术。请诚实地回答以下的问题。

Marital Status 婚姻状况:SMDW

How Did You Hear About Us? 您是如何知道我们?
Wanbao 晚报Shin Min 新明NE / SE Magazine 东北/ 东南杂志Internet Search 网际网络Voices 杂志Zao Bao 早报Website 网站MD Referral 医生推荐Physical Therapist Referral 物理治疗师推荐Facebook 脸书Chiropractic Referral 脊椎神经医生推荐

Would You Consider This Problem (check one): 你会考虑这个问题（选一）：
MINIMAL (Annoying but causing NO limitations) 极小（懊恼，但没有造成局限）SLIGHT (Tolerable but causing a little limitation) 轻微（可容忍，但造成一点点的局限）MODERATE (Sometimes tolerable but definite cause of limitations) 中等（有时可容忍，但有一定的局限）SEVERE (Causing Significant limitations) 严重（造成重大的局限）EXTREME (Causing near constant limitations) 极端（造成恒久的局限）

Is your problem/concern： 您的问题/症状：
Improving 在进步Worsening 在恶化Not Changing 没变化

Has your problem affected your balance: 您的问题是否有影响平衡：
Yes 有No 没有

What kind of treatments have you received for your problem/pain? 您接受过什么样的治疗？
Physical Therapy 物理治疗 Chiropractic 脊椎矫正Acupuncture 针灸Pain Medications 止痛药物 TCM 中医

Does your pain wake you up at night? 您半夜会因疼痛而醒来吗？

The last section of this application is the General Health History Section. Please complete this section thoroughly and answer to the best of your knowledge. 最后一页是一般的健康历史资料。请彻底完成并给予最佳的答案。

Indicate the location(s) you have pain and/or altered sensation:
请标明您有疼痛和/或异常感觉的位置：

Do you have or had in the past any trouble with：
您是否有或曾经有过：
Nervous System 神经系统
Pins & Needles 针刺感觉Numbness 麻痹Insomnia 失眠Dizziness 头晕Tinnitus（ear noise）耳鸣Burning Sensation 刺热感觉Depression 沮丧感Bed Wetting 尿床Headache 头痛

Cardiovascular System 心血管系统
Rapid Heart Rate 心脏加速Heart Attack 心脏病Heart Palpitations 心悸High Blood Pressure 高血压Stroke 中风High Cholesterol 胆固醇

Reproductive System 生殖系统
Low Fertility 底生育率Miscarriage 流产Pain during Menses 经痛Irregularity Menses 经期不规律

Urinary System 泌尿系统
Retained Fluid 排便不滔，有保留Painful Urination 排尿疼痛Kidney Stone 肾结石Loss of Bladder Control 膀胱失调Frequent Urination 频尿

Respiratory System 呼吸管
Emphysema 气肿Sinus problem 鼻翼问题Chronic Cough 长期咳Asthma 哮喘

Digestive System 消化系统
Constipation 便秘Irritable Bowel SyndromeDiarrhea 腹泻Ulcer 溃疡

Other 其他
Frequent Cold 惯性感冒Cancer 癌症Diarrhea 腹泻Diabetes 糖尿病