Name:

John Leung, MD DOB:

Boston Food Allergy Center
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
DOS
Tel: (617) 804-6767 Fax: (877) 726-8492

CIVIL SURGEON PATIENT INTAKE FORM

Have you brought with you the following?

 Government-issued photo identification 政府發放有照片的證明文件(例如護照或駕駛執照)

 Relevant medical records (must be in English) 醫療記錄
 Vaccination or immunization record 防疫針的紀錄
 Proof of prior treatment for TB or other infectious disease(s), if any 肺結核有關的病歷紀錄
 Medical insurance card, if any (may cover some of the tests required) 保險醫療卡
 Payment (money order or cash). No personal check or credit card. 費用(現金或銀行本票)
 Fill out i-693 first 2 pages and email rwilkinson@bostonfoodallergycenter.org

PATIENT INFORMATION:

Last name Pharmacy address

英文姓 藥房
First name
英文名字
Middle name
英文中间名字
Cell phone
手提電話
Email Home address
電郵地址 住址
Primary care MD
家庭醫生姓名
Alien registration
number
外國人註冊號碼
CITY OF BIRTH Country of birth:
出生省份 出生國家
Date of birth:
出生日期

CURRENT MEDICATION 藥物:

Name 藥物名字 Dose 份量 Frequency 每日次數

DRUG ALLERGIES 藥物敏感: [ ] NO 冇; [ ] YES 有: ________________

ANY DISEASES RUN IN FAMILY 家族病史: [ ] NO 冇; [ ] YES 有:_______________

Civil surgeon intake form updated on 9-5-2016 JL

 Name:
John Leung, MD DOB:
Boston Food Allergy Center
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
DOS
Tel: (617) 804-6767 Fax: (877) 726-8492

SOCIAL HISTORY:
No 冇 Yes 有
SMOKE 食煙
ALCOHOL 飲酒
RECREATIONAL DRUG USE 吸毒
OCCUPATION 職業
HARMFUL BEHAVIOUR有害行為

Circle the symptoms if you have any 如有以下症狀, 請圈

General symptoms: Neurological: Genitourinary:
Fever, swollen glands, change in vision, Headaches, weakness, loss of Burning sensation
hearing loss, sore throat, runny nose, sensation, numbness, falling, while urinating,
skin changes, joint/muscle pain,
oral/genital sores, rash, change in
dizziness, depression, anxiety blood in urine,
weight, change in appetite 頭痛，虛弱，感覺喪失，麻木 genital discharge,
發熱，淋巴結腫大，視力改變，聽力下降，咽痛，流鼻 ，下降，頭暈，抑鬱症，焦慮 genital itching
涕，皮膚改變，關節/肌肉疼痛，口腔/生殖器潰瘍，皮疹 排尿灼燒感，尿中帶
血，外陰分泌物，外
，體重變化
陰瘙癢

Heart and Lungs: Abdominal: Other 其他:

Chest pain, irregular heartbeat, cough, sputum, blood Nausea, vomiting, jaundice,
in sputum, wheezing, shortness of breath, abnormal abdominal pain, heartburn,
chest x-ray difficulty swallowing,
胸部疼痛，心律不齊，咳嗽，咳痰，痰中帶血，氣喘， diarrhea, constipation,
呼吸急促，異常胸部x-射線 bloody stools
噁心，嘔吐，黃疸，腹痛，胃
灼熱，吞嚥困難，腹瀉，便秘
，便血

MAJOR ILLNESS疾病 YES NO DATE OF ONSET PHYSICIAN NOTE

有 冇
ASTHMA哮喘
TUBERCULOSIS 肺結核
HEART PROBLEMS心臟疾病
HYPERTENSION 高血壓
THYROID DISEASE 甲狀腺疾病
STROKE中風

Civil surgeon intake form updated on 9-5-2016 JL

 Name:
John Leung, MD DOB:
Boston Food Allergy Center
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
DOS
Tel: (617) 804-6767 Fax: (877) 726-8492

SEXUALLY TRANSMITTED Dx 性病
HIV/AIDS 愛滋病
DIABETES 糖尿病
REFLUX/HIATAL HERNIA 胃酸倒流
GALLBLADDER DISEASE 膽病
HEPATITIS/LIVER DISEASE 肝病
COLITIS/CROHN’S DISEASE 腸炎
CANCER癌症
HEADACHE 頭痛
MENTAL DISORDER 精神障礙
DEPRESSION/ANXIETY 抑鬱/焦慮
SEIZURE/EPILEPSY 癲癇/癲癇
PHYSICAL IMPAIRMENT 身體損傷
OTHERS 其他

Quest Diagnostic closest to you (抽血化驗室):

https://secure.questdiagnostics.com/hcp/psc/jsp/SearchLocation.do?newSearch=FindLocation

Fill out as much as you can Date received Date received Date received Date received
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
注射日期 注射日期 注射日期 注射日期
(月/日/年) (月/日/年) (月/日/年) (月/日/年)
DT/DTap/DTP
Td/Tdap
OPV/IPV
MMR
Hib
Hep B 乙型肝炎
Varicella 水痘
Pneumococcal 肺炎球菌
Influenza 流感
Rotavirus 輪狀病毒
Hep A A型肝炎
Meningococcal 腦膜炎雙球菌

Civil surgeon intake form updated on 9-5-2016 JL