禅武医调理问诊表

为了更好地为您的健康服务,请花几分钟填写下表,谢谢! To serve your health better, please take a few minutes to fill out the following form, thank you ~
姓名 Name
    ____________
性别 Gender
男 Male
女 Female
年龄 Age
    ____________
联系方式 Mobil
    ____________
请问您从哪里了解到少林中心有禅武医调理?How do you know here?
    ____________
目前身体不适的症状与调理诉求 Symptoms of current physical discomfort
    ____________
其他您希望师父提前了解的身体情况,例如手术、外伤、慢性病等  Other physical conditions that you would like shifu to know in advance, such as surgery, trauma, chronic diseases, etc
    ____________
您使用过以下哪种养生方式 Which of the following health regimen have you used?
推拿 massage
正骨 bonesetting
针灸 acupuncture
艾灸 moxibustion
其他 others
平时运动锻炼项目?频次如何?What do you do for physical exercise?frequency?
    ____________

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