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健康評量表
Personal Health Questionnaire
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* Indicates required question
請認真填寫～您的認真程度將會決定您的速度！
姓名 Name
*
Your answer
聯絡電話 Phone Number
*
Your answer
方便聯絡時間 Convenient to contact times
*
早上 09:00~12:00 Morning
下午 12:00~18:00 Afternoon
晚上 18:00~21:00 Evening
任何時候 Anytime
Required
居住地址 Residential Address
Your answer
基本資料 Basic information
性別 Sex
*
男 Male
女 Female
年齡 Age
*
Your answer
身高 Height
*
（CM）
Your answer
體重 Weight
*
（KG）
Your answer
體脂肪 Body Fat
Your answer
目前工作 Current work
*
如唸書請填學生 / If school please fill out student
Your answer
你是認真想要增重、減重、保健嗎？
*
Are you seriously?
我是認真的想要增重 I'm seriously to add my weight
我是認真的想要減重 I'm seriously to loss my weight
我是認真的想要保健 I'm seriously to find a health way having nutrition
我只是說說而已 Just kidding
Required
Facebook／Line id／Skype
*
網路聯絡方式 Network contact
Your answer
想要減重／增重多少 KG？ 全身胖 或 局部胖？保健者請填健康上的問題 。Want to weight loss／weight gain how many KG?
*
例：減重 10 KG/ 胖下半身
Your answer
你為什麼 變胖／ 變瘦？ Why do you get fat／why do you get thin?
*
產後 After Pregnancy
藥物 Medicine
從小胖/瘦 From Childhood
喜歡甜食或油炸 Like Desserts/Fried food
三餐不定時或節食 Irregular Meals or Eat Nothing
暴飲暴飲或食量大 Eat a lot of Food
情緒困擾 Emotion distress
內分泌問題 Endocrine problems
吃宵夜 Eating others after dinner
便秘 Constipation
上夜班（熬夜23:00後才睡）Night shift/Stay up
喝水低於2000cc Drink water less then 2000cc
Other:
Required
你以前試過怎樣方式？為什麼沒有效果？ Have you ever tried how to approach? Why is there no effect?
*
例：運動 / 沒有持續力
Your answer
這次為什麼想要 改變的理由？ The reason for why you want to change?
*
一定要(瘦/胖/健康)的原因（因為我男友會嫌棄~健康出問題~爬樓梯會喘...等等）請至少填二十個字！
Your answer
你的減重/增重決心有幾分？ How serious of your weight loss/weight gain determination?
*
5分代表可有可無（1分代表我死也不改變/5分代表我改不改都沒差/10分代表我非改變不可）
完全沒決心
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這輩子最後一次減重/增重/調體質
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