Inquiry form

Filling in the inquiry form with student and parents

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Basic Information
Name
Sex Male    Female
Date of birth year month day
Grade Grade
Tel
Mobile (parents)
Address
Height of student cm
Weight of student kg
Height of father cm
Height of mother cm
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Sleep
Do you fall asleep within 30 minutes? Yes   Sometimes   No
Do you sleep more than 7 hours? Yes   Sometimes   No
After you wake up in the morning, do you feel refreshed? Yes   Sometimes   No
Do you get a lot of dream, when you sleep? Yes   Sometimes   No
Exercise
Do you exercise on a regular basis? Yes   Sometimes   No
If you answered “yes”, how many hours do you exercise a day? Less than 30 minutes   More than 1 hour
What kind of exercise do you do?
Meal
These days I have a good appetite. Yes   Sometimes   hardly drink
I drink more than 500cc (2 small cups) of milk a day. Yes   Sometimes   hardly drink
I eat dairy products (cheese) more than once a day. Yes   Sometimes   hardly drink
I eat anchovies more than once a day. Yes   Sometimes   hardly drink
I eat meat more than once a day. (pork, beef, and etc) Yes   Sometimes   hardly drink
I eat fish more than three or four times a week. Yes   Sometimes   hardly drink
I eat eggs more than three or four times a week. Yes   Sometimes   hardly drink
I usually have a good breakfast. Yes   Sometimes   No
I eat well-balanced meals. Yes   Sometimes   No
I normally eat 2 hours before I go to bed. Yes   Sometimes   No
I eat junk food more than three or four times a week. Yes   Sometimes   Often
I drink coke or soft drinks more than once a day. Yes   Sometimes   Often
Etc
have diarrhea or constipation. No / Yes  ( Constipation   Diarrhea)
I have a bloated stomach and often experience flatulence. No   Yes
I have indigestion. No   Yes
I often have nasal congestion. No   Yes
I often cough without having a fever. No   Yes
I easily catch a cold or it takes me long time to recover from it. No   Yes
I often have a tonsillitis, or a sore throat, or an inflammation of the middle ear. No   Yes
I often have nosebleeds. No   Yes
I often twist my arm or ankle. No   Yes
I often have spasms or cramps. No   Yes
I wet my bed at night or I wet my pants during the daytime. No   Yes
I sometimes have murky urine. No   Yes
I often bloat when I wake up. No   Yes ( Hands Feet Eyes)
I often feel dizzy. No   Sometimes   Often
I often have a headache. No   Yes
If you suffer any disease , please name it(them).
Please complete the following questions, only if you are a middle school student or older.
I often panic or my heart pounds a lot when I’m nervous. No   Yes
My neck gets stiff and my eyes get tired easily. No   Yes
Female students only
When was your first period?
I have severe cramps during my period. No / Yes ( Waist Belly Breasts )
I have severe vaginal discharge. No   Yes
My hands , feet, or my stomach often get cold. No   Yes
Additional items (Write notes please)
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