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Matab-Registration Form- فرم تشکیل پرونده درمانی

لطفاً فرم زیر را به طور کامل پر کنید . جواب دادن به تمام سوالات اجباری می باشد.

Please fill the form below completely so we can help you solve your issues. All the fields have to be filled.

Vul het onderstaande formulier volledig in, zodat we u kunnen helpen bij het oplossen van uw probleem.

Name (Name) نام، . نام خانوادگی *

Date of Birth تاریخ تولد *

E-mail

Payment information (Betaling info.) اطلاعات پرداخت *

Tel. No. شماره تلفن *

Place of residence (Home town) محل سکونت *

How often a week do you eat red meat? (How often do you eat red meat per week?) چند بار گوشت قرمز می خورید؟

Seldom (rarely)
2 -3 times a week (2-۳ 3 times a week)
More than 3 times ( more than three times ۳)

How often a day do you eat fruit? (How often do you eat fruit per day?) چند بار در روز میوه می خورید؟

Seldom (rarely)
2 -3 times a week (2-۳ 3 times a week)
More than 3 times ( more than three times ۳)

How often do you eat white meat (chicken/fish)? (How often do you eat white meat (fish/chicken) مصرف گوشت سفید(مرغ و ماهی) دارید؟

Seldom (rarely)
2-3 times a week (2-۳ 3 times a week)
More than three times ( More than ۳ 3 times)

Do you drink alcohol? (Do you drink alcohol?) الکل می نوشید؟

Seldom (rarely)
Yes (Yes)

Do you smoke? (Do you smoke?) سیگار می کشید؟

No (No)
Yes (Yes)

Do you have a headache or dizziness? (Do you headache or dizziness?) آیا سرگیجه یا سردرد دارید؟

No (No)
Yes (Yes)

How often do you walk more than 2 km/week? (How often do you walk more than 2km/week?) چند باردر هفته بیشتر از 2 کیلومتر قدم می زنید؟

Rare (Seldom)
2-3 times a week (2-۳ 3 times a week)
More than three times ( More than ۳ 3 times)

How do you weigh (kg) your length (cm)? (How much do you weigh (kg)/ your height (cm)?) وزن شما (کیلوگرم) / قد شما (سانتی متر) چقدر است؟ *

What are the conditions of your skin/hair/teeth/eyes? (What are the conditions of your skin/hair/teeth/eyes?) شرایط پوست / مو / دندان / چشم شما چیست؟ *

Do you use medication (name)? (Are you taking medication (which)? ) آیا از دارو استفاده می کنید (کدام)؟ چقدر؟ *

What will happen if you don't take your medication? (What happens if you don't take your medication?) اگر از داروی خود استفاده نکنید چه اتفاقی می افتد؟ *

What exactly is it that you want to achieve with therapy? (What is it exactly that you want to achieve from this therapy?) درمان چه چیز یا مشکلاتی را از ما میخواهید؟ *

Have you ever had surgery? Please explain. (Have you had any operations before? Please explain )آیا قبلاً عمل کرده اید؟ لطفا توضیح دهید. *

How is your general health/condition? (How is your general condition?) وضعیت عمومیتان چگونه است *

Kunt u lopen of moet je in bed liggen? Can you walk or do you have to lie in bed? ایا می توانید قدم بزنید یا بستری هستید؟

These fields below are for women (the files below are for ladies) فضای زیر مخصوص بانوان می باشد *

Deze onderstaande velden zijn voor dames (the files below are for ladies) فضای زیر مخصوص بانوان می باشد

How's your priode? How's your period? وضعیت پریود شما چگونه است؟

How many children do you have? How many childeren do you have? چند فرزند دارید؟

Hebt u een baby? Do you have an infant? بچه شيرخواره داريد؟

Where have you heard from us? (How did you find us?) چگونه ما را پیدا کردید؟ *

Comment or Message (پیغام) *

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