無恙諮詢個案表

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無恙諮詢個案表

All Is Well Customer Form

聯繫資訊 Contact Information

姓名 Name

電話 Phone

電子郵件 Email

郵寄地址 Shipping address

症狀調查 Investigation on symptoms

過敏 Allergies

鼻過敏 Nasal allergy

氣喘 Asthma

皮膚炎 Dermatitis

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睡眠障礙 Sleep disorders

打鼾 Snoring

睡眠呼吸中止 Sleep apnea

失眠 Insomnia

淺眠 Sleep light

多夢 Epic dreaming

頻醒 Frequent nigh waking

難入眠 Difficult to fall asleep

夜間小腿抽筋 Night time leg cramps

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口腔症狀 Oral symptoms

口臭 Bad breath

口乾 Dry mouth

喉痛 Sore throat

牙周病 Periodontal Disease

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消化道問題 Gastrointestinal disorder

腸胃脹氣 Intestinal gas

胃食道逆流 Gastroesophageal reflux disease

腸炎 Inflammatory bowel disease

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筋膜疼痛 Fascia Pain

磨牙 Bruxism

肩頸僵硬 Cervicobrachial syndrome

肢體痠麻 Limb soreness

關節痛 Joint Pain

全身性不明疼痛 Fibromyalgia

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其他疼痛症狀 Other Pain symptoms

其他身體不適 Other discomforts

治療調查 Investigation on treatments

目前服用什麼藥物?

What medicines you're taking now?

是否使用醫療用具（如正壓呼吸器、止鼾器、洗鼻器等）？

Do you use any medical equipments (i.e. CPAP, anti-snoring appliance, nasal irrigator, etc. )?

是否做過手術？

Have you had surgery?

是否做過睡眠檢測？睡眠呼吸中止程度為何？

Have you had sleep apnea test? Your AHI?

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