女性就诊健康信息采集表 Current Visit Information

尊敬的女士：
您好！请如实填写以下全部信息，内容仅用于本次医疗评估，我院严格保护患者隐私，所有资料不会向第三方泄露，请放心填写。
Dear Madam,
Please fill in all information truthfully. All data is only used for your medical evaluation. Distinct Healthcare strictly protects patient privacy and will never disclose your information to any third party.
*
1.
知情声明 Declaration
题目内容：本人确认此问卷填写信息是真实、准确的。本信息仅供患者本人及医疗评估使用，未经患者同意，不得向第三方透露。卓正医疗致力于保护患者信息的保密性和隐私性。
I certify that the following information is true and accurate. This information is intended solely for the patient and for medical evaluation purposes. Without the patient’s explicit consent, it must not be disclosed to any third party. Distinct Healthcare is committed to ensuring the confidentiality and privacy of patient information.
已阅读并确认 Read and Confirmed
*
2.
您之前是否在卓正体检过？Have you had health checkup at Distinct Healthcare before?
是 Yes
否 No
*
3.
种族 Race
亚裔 Asian
白人 White
黑人/非洲裔 Black/African American
西语裔/拉丁裔 Hispanic/Latino
选择不透露 Prefer not to disclose
其他 Other
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4.
您目前有无药物、食物或其他物品过敏？（如有请写出过敏药物、食物或其他名称。）Do you have any allergies to drugs, food, or other items?（If yes, please list names of drugs, food, or other items here.）
有 Yes
无 No
*
5.
最近一个月您是否有在使用药物？（说明：如是请写出药名和用法用量。）Have you taken any medications in the past month?
（If yes, please list names of medications/dosages/frequencies here.）
是 Yes
否 No
*
6.
您目前有什么健康问题或不适？（说明：如是请补充。）Do you have any health issues?
（If yes, please list here.）
是 Yes
否 No
*
7.
您是否患有明确诊断的慢性疾病？Have you ever been diagnosed with any chronic conditions?
是 Yes
否 No
*
8.
您是否有明确诊断的肿瘤？Have you been diagnosed with cancer?
是 Yes
否 No
*
9.
您的一级亲属（父母，子女或兄弟姐妹）是否患有诊断明确的肿瘤/疾病？Do your blood relatives (parents, children or sibling) have a diagnosed cancer/disease?
是 Yes
否 No
*
10.
您是否曾经有过手术？（说明：如是请填写手术名称及手术年份。）Have you had surgery before?（If yes, please list name and year of surgery.）
是 Yes
否 No
*
11.
您是否吸烟？Do you smoke?
是 Yes
否 No
已戒烟 Ex-smoker
*
12.
您日常有喝酒么（平均每周饮酒1次以上）？Do you drink alcohol (more than 1 drink per week on average)?
是 Yes
否 No
已戒酒1年以上 Quit
*
13.
是否接种过HPV疫苗（宫颈癌疫苗）？Have you received HPV vaccine?
是 Yes
否 No
*
14.
您既往是否做过宫颈癌筛查？Have you ever had a PAP smear/HPV test?
是 Yes
否 No
不清楚 Uncertain
广泛性焦虑障碍量表 (GAD-2) Generalized Anxiety Disorder 2-item

在过去的2周里，您被以下问题困扰的频率是多少？Over the last 2 weeks, how often have you been bothered by the following problems?
从不 = 0分 Not at all = 0 points
偶尔几天 = 1分 Several days = 1 point
大多数日子 = 2分 More than half the days = 2 points
几乎每天 = 3分 Nearly every day = 3 point
*
15.
感到紧张、焦虑或烦躁 Feeling nervous, anxious, or on edge
从不 Not at all
偶尔几天 Several days
多数日子 More than half the days
几乎每天 Nearly every day
*
16.
无法停止或控制担忧 Not being able to stop or control worrying
从不 Not at all
偶尔几天 Several days
大多数日子 More than half the days
几乎每天 Nearly every day
模块标题：患者健康问卷 (PHQ-2) Patient Health Questionnaire-2

说明文字：在过去的2周里，您被以下问题困扰的频率是多少？Over the last 2 weeks, how often have you been bothered by the following problems?
从不 = 0分 Not at all = 0 points
偶尔几天 = 1分 Several days = 1 point
大多数日子 = 2分 More than half the days = 2 points
几乎每天 = 3分 Nearly every day = 3 point
*
17.
对做事情提不起兴趣或感到愉悦 Little interest or pleasure in doing things
从不 Not at all
偶尔几天 Several days
大多数日子 More than half the days
几乎每天 Nearly every day
*
18.
感到沮丧、抑郁或无望 Feeling down, depressed, or hopeless
从不 Not at all
偶尔几天 Several days
大多数日子 More than half the days
几乎每天 Nearly every day
19.
其他补充描述（如有） Additional description (if any) （255字以内）
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