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Advanced Pain Centres offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

If you do not already have AdobeReader® installed on your computer, Click Here to download.
Download the necessary form(s), print it out and fill in the required information.
Fax us your printed and completed form(s) or bring it with you to your appointment.

Please fill out ONE of the following forms based on your condition. If you have any questions on which form applies, please contact us by email (Click Here) or call us:

Kovan branch: 6287 9655

Tampines branch: 6782 6682

Toa Payoh branch: 6258 6160

Jurong branch: 6425 5368

New Patient Application Forms – Required

This lets us know the history and current state of your health and if you are a current candidate for our care.

Adult Treatment Application Form – English and Mandarin

Intake Child – English/Mandarin

Adult Booking Form
Child Booking Form

Adult Booking Form

Adult Treatment Application Form

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。

Date of Birth 出生日期

Gender 性别

Do you wish to receive our newsletter through email on the latest health tips on wellness, nutrition and exercise?
您希望通过电子邮件收到最新的健康，营养和运动资讯？

Marital Status 婚姻状况:SMDW

No. of children 几个孩子:

Pregnant 怀孕? :

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

How many spinal injections? 脊髓注射多少次?

Date of Last Injection 最后注射日期

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

Yes 会No 不会

Have you ever been diagnosed with osteoporosis?
您曾经被诊断患有骨质疏松症吗?

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：

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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

Do you consent to allowing us to contact you for patient feedback, for appointment bookings and feedback and promotions. 您是否同意允许我们与您联系以获取患者反馈意见，预约,反馈意见和促销
YES 同意NO 不同意

Child Booking Form

Child Health Information Form

Child Health Information Form 儿童健康表格

Date of Birth 出生日期

Gender 性别

During Pregnancy 怀孕期间

Was the child s mother on any medication? 小孩母亲是否曾服用药物？

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Was there back pain? 背部疼痛？

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Was the child s mother physically ill? (Colds, flu, allergies, measles etc.)
小孩母亲是否常患有：感冒，伤风，敏感，麻疹等等？

Regarding Labor 关有分娩

Was it chemically induced? 摧生？

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Was a C-section performed? 剖腹生产？

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Were forceps used? 用钳子?

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Did doctor have hands on the infant? 医生在旁协助?

(95% of all infants were born with hands on or forceps)（95%的婴儿出生时都有医生在旁协助或用钳子）
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Was the baby premature? 早产婴儿？

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Does/did the child suffer from any of the following? 小孩是否有或曾经有过？
Headaches 头痛Sleeping disorders 睡眠失调Breathing trouble 呼吸困难Irritability 烦躁Frequent colds 感冒Bloody noses 流鼻血Diarrhea 腹泻Colic 腹痛Milk Intolerance 不可喝牛奶Digestive issues 消化问题Ear Infections 耳朵感染Allergies 敏感Fatigue 疲倦Hyperactivity 极度活跃Frequent Flu 伤风Meningitis 脑膜炎Constipation 便秘Rashes 疹Bed wetting 尿床

Does/did the child 小孩是否有或曾经
Seem accident prone? 易于意外？Ever fallen down steps? 曾经从梯级跌下?Ever been in a motor vehicle accident? 发生过交通意外?Ever been hospitalized or had surgery? 住院或动手术?Ever broken bones or had sprains? 骨折或扭伤?Have poor posture? 不正确姿势?Seem nervous or shy? 易紧张不安或害羞？

What activities does the child participate in? 小孩参加什么活动？

What are the main health concerns? 最主要关切的健康问题是什么？

Do you consent to allowing us to contact you for patient feedback, for appointment bookings and feedback and promotions. 您是否同意允许我们与您联系以获取患者反馈意见，预约,反馈意见和促销.
YES 同意NO 不同意