Proposal Form Questions (Standard)

Family History:Have any of your biological parents, brothers or sisters ever suffered from heart diseases, stroke, hypertension, diabetes, kidney disease, mental disorders, cancer, hereditary, neurological or congenital disease? If “YES”, please give details in the Supplementary Sheet (attaching to and forming part of the Proposal For Assurance / Proposal For Assurance (Third Party)).

家族病史：您的亲生父母，兄弟或姐妹是否曾经患有心脏疾病，中风，高血压，糖尿病，肾脏病，精神障碍，癌症，遗传，神经或先天性疾病？如”YES”,请列在有关表格。

IF YES

Brother,          Father,          Mother,          Sister,         Age Diagnosis:___

Have you ever smoked or use any tobacco / nicotine product (eg. Cigarettes, cigar or pipes) in the last 12 months?

在过去12个月内，您是否曾吸食或使用任何烟草/尼古丁产品（例如香烟、雪茄或烟斗）？

Do you consume alcoholic drinks?
___Beer/Stout     ___Wine     ___Whiskey/Brandy/Others     ___Social Drinker

您是否有喝酒精类的饮料？

Are you currently receiving medical treadment and/or suffering from physical impairment or infirmity, congenital abnormality?

您目前是否有接受医药疗程和/或身体、精神上出现伤痕、体弱、先天性缺陷？

Have you ever taken or do you now take any drugs or narcotics, other than those validly prescribed by doctors, or been treated for drug habits?

您以前或目前是否有服用任何有害药物或毒物或其他如医生开给您的合法药物，或正在戒毒治疗中？

Have you ever had, been diagnosed to have, been investigated, treated or advised to seek any medical or surgical treatment for any conditions listed below:

以下是问您以前是否有患上、被告知您已患上或从哪里患上疾病，或有接受过任何医疗疗程的问题

Stroke, transient ischemic attack (TIA), brain hemorrhage or brain injury, epilepsy, convulsion (fits), paralysis, Parkinson’s disease, Alzheimer’s disease, Multiple sclerosis, prolonged recurrent dizziness or headache, migraine, cerebral palsy or other disease or disorder of the brain or nervous system?

中风，短暂性脑缺血发作 (小中风)，脑出血，脑损伤，癫痫症，痉挛，瘫痪，帕金森，老年痴呆症，多发性硬化，长期持续晕眩或头痛，偏头痛，脑性瘫痪症或其他关于脑的疾病或神经系统的问题？

IF YES

1. Stroke – 中风
2. Transient ischemic attack (TIA) – 短暂性脑缺血发作(小中风)
3. Brain hemorrhage or brain injury – 脑出血或脑损伤
4. Convulsion (fits) – 痉挛
5. Parkinson’s – 帕金森
6. Alzheimer’s – 老年痴呆症
7. Prolonged recurrent dizziness or headache – 长期持续晕眩或头痛
8. Migraine – 偏头痛
9. Paralysis – 瘫痪
10. Cerebral palsy – 脑性瘫痪症
11. Multiple sclerosis – 多发性硬化
12. Other disease or disorder of the brain or nervous system – 其他关于脑的疾病或神经系统的问题
    

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13. Headache – 头痛
    Last attack within past 6 months
    Last attack more than 6 months ago

    Hospitalised and fully recovered – 住院并完全康复
    Not hospitalised and fully recovered with no recurrence – 未住院且完全康复，未复发

    ---

14. Epilepsy – 癫痫症
    Last attack within than 6 months
    Last attack more than 6 months ago

    On treatment/ medication 关于治疗/药物治疗
    Off treatment/ medication and fully recovered 停止治疗/ 药物治疗并完全康复

Depression, anxiety, schizophrenia, suicide attempt, attention deficit hyperactivity disorder (ADHD), autism, Down’s syndrome, dementia, or any other mental health or psychiatric illness?

抑郁症，焦虑，精神分裂症，自杀倾向，注意力不足過动症，自闭症，唐氏综合征，痴呆症，或其他关于心理健康及精神疾病的问题？

IF YES

1. Anxiety – 焦虑
2. Attention deficit hyperactivity disorder (ADHD) – 注意力不足過动症
3. Autism – 自闭症
4. Dementia – 痴呆症
5. Depression – 抑郁症
6. Down’s syndrome – 唐氏综合征
7. Schizophrenia – 精神分裂症
8. Suicide attempt – 自杀倾向
9. Other mental health or psychiatric illness – 其他关于心理健康及精神疾病的问题

Asthma, bronchitis, tuberculosis (TB), pneumonia, coughing of blood or any other disease or disorder of the lungs or respiratory system?

气喘，支气管炎，肺结核，肺炎，咳血或其他关于肺部或呼吸系统的问题？

IF YES

1. Asthma – 气喘
   Last attack within past 2 years
   Last attack more than 2 years ago

   Currently on treatment/ medication – 目前正在接受治疗/药物治疗
   Currently off treatment/ medication – 目前正在停止治疗/药物治疗

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2. Bronchitis – 支气管炎
   Last attack within past 2 years
   Last attack more than 2 years ago

   Hospitalised and fully recovered – 住院并完全康复
   Hospitalised and not fully recovered  – 住院且尚未完全康复
   Not hospitalised and fully recovered – 没有住院并完全康复
   Not hospitalised and not fully recovered – 未住院且未完全康复

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3. Tuberculosis (TB) – 肺结核
4. Pneumonia – 肺炎
5. Coughing of blood 咳血
6. Other disease or disorder of the lungs or respiratory system – 其他关于肺部或呼吸系统的问题

Chest pain, angina, palpitation, irregular heartbeat, coronary artery disease (heart disease), heart attack, raised cholesterol, hypertension (high blood pressure), hypotension (low blood pressure), heart valve disorder, cardiomyopathy (enlarged heart), heart defects from birth or heart surgery, deep vein thrombosis, varicose veins or any other disease or disorder of the heart or vascular system?

胸痛，心绞痛，心悸，心律不齐，冠状动脉病，心脏病，高胆固醇，高血压，低血压，心瓣膜病症，心肌肿大症，先天性心脏缺陷或心脏手术，深部静脉栓塞，静脉曲张的血管或其他关于心脏的疾病或血脉系统的问题？

IF YES

1. Angina – 心绞痛
2. Cardiomyopathy (enlarged heart) – 心肌肿大症
3. Chest pain – 胸痛
4. Coronary artery disease (heart disease) – 冠状动脉病
5. Deep vein thrombosis – 深部静脉栓塞
6. Heart attack – 心脏病
7. Heart defects from birth or heart surgery – 先天性心脏缺陷或心脏手术
8. Heart valve disorder – 心瓣膜病症
9. Hypertension (high blood pressure) – 高血压
10. Hypotension (low blood pressure) – 低血压
11. Irregular heartbeat – 心律不齐
12. Palpitation – 心悸
13. Raised cholesterol – 高胆固醇
14. Varicose veins – 静脉曲张的血管
15. Other disease or disorder of the heart or vascular system – 心脏或血管系统的其他疾病或障碍

Diabetes, abnormal blood sugar, thyroid disease, goiter, thalassemia, anaemia, haemophilia or other disease or disorder of the endocrine glands, blood, chromosomal abnormality or hereditary disease?

糖尿病，超标血糖，甲状腺疾病，甲状腺肿，地中海贫血，贫血症，流血不止症，或其他关于内分泌腺的血液，染色体不正常或遗传病的问题？

IF YES

1. Abnormal blood sugar – 超标血糖
2. Anaemia – 贫血症
3. Diabetes – 糖尿病
4. Goiter – 甲状腺肿
5. Haemophilia – 流血不止症
6. Thalassemia major – 重型地中海贫血
7. Thyroid disease – 甲状腺疾病
8. Other disease or disorder of the endocrine glands, blood, chromosomal abnormality/hereditary disease
   其他内分泌腺、血液、染色体异常/遗传性疾病的疾病或紊乱
   

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9. Thalassemia minor or trait 轻型地中海贫血或特征
   Without history of anaemia or symptoms – 无贫血病史或症状
   With history of anaemia or symptoms – 有贫血病史或症状
   

Gastritis, gastric or duodenal ulcer, gastro-oesophageal reflux disease (GERD), colitis, Crohn’s disease, hernia, fistula, piles, blood in stool, vomiting blood or other disease or disorder of the digestive system or gastrointestinal tract?

胃炎，胃痛或十二指肠溃疡，胃食管返流疾病，大肠炎，节段性肠炎，疝气，瘘管，痔疮，血便，吐血，或其他关于消化及肠胃道系统的问题？

IF YES

1. Blood in stool 血便
2. Colitis 结肠炎
3. Crohn’s disease 节段性肠炎
4. Vomiting blood 吐血
5. Other disease or disorder of the digestive system or gastrointestinal tract 消化系统或胃肠道的其他疾病或紊乱
   

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6. Gastritis/Gastric Pain/Epigastric Pain – 胃炎/胃痛/上腹痛
7. Gastric Ulcer or Duodenal Ulcer – 胃溃疡或十二指肠溃疡
8. Gastric-oesophageal reflux diease/GRED or Oesophagitis – 胃食管反流病/食管炎
   

   No history of hospitalisation or operation responsive to treatment without complications
   没有住院或手术的病史，对治疗有良好的反应且没有并发症。

   No history of hospitalisation or operation, not responsive to treatment or with associated complications/residuals –
   没有住院或手术的病史，对治疗无反应，或伴有并发症/残留问题。

   With history of hospitalisation or operation responsive to treatment without complications –
   有住院或手术的病史，对治疗有良好的反应且没有并发症。

   With history of hospitalisation or operation, treated with associated complications/residuals –
   有住院或手术的病史，治疗过程中出现了相关并发症或残余问题。

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9. Helicobacter Pylori (H.pylori) Infection – 幽门螺旋菌感染
   Less than 2 years
   More than 2 years
   Without symptoms, fully eradicated with confirmatory test – 无症状，通过确诊测试，完全根除
   Without symptoms, fully eradicated without confirmatory test – 无症状，无需确诊测试，即可彻底根除
   Without symptoms, not fully eradicated – 无症状，未完全根除
   Others:
   

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10. Fistula – 瘘管 (肛)
    Less than 2 years
    More than 2 years
    Operation done and fully recovered – 手术完成，并完全康复
    Operation done and not fully recovered – 手术已完成，但未完全恢复
    No operation done and not fully recovered – 未做过手术，且未完全恢复
    No operation done and fully recovered – 未做任何手术，已完全康复
    

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11. Hernia – 疝气
      Operation done and fully recovered without complications
      手术已完成，完全康复，没有并发症
      Operation done and not fully recovered
      手术已完成，但尚未完全康复。
      No operation done and fully recovered (without symtoms and not on treatment)
      没有进行手术，完全康复，没有症状并且没有在接受治疗
      No operation done and not fully recovered
      没有进行手术，且尚未完全康复。
    

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12. Piles/ Haemorrhoids – 痔疮
      Operation done and fully recovered with no recurrence
      手术完成，完全康复，未再复发
      Operation done and not fully recovered
      手术已完成，但尚未完全康复
      No operation done and fully recovered (without symtoms and not on treatment)
      没有进行手术，完全康复，没有症状并且没有在接受治疗
      No operation done and not fully recovered
    没有进行手术，且尚未完全康复

Jaundice, Hepatitis B or C, gall bladder or biliary system stone or obstruction, pancreatitis or other disease or disorder of the liver, gall bladder, biliary system or pancreas?

黄疸病，B或C型肝炎，胆囊或胆结石或梗阻，胰腺炎或其他关于胆系统的问题

IF YES

1. Biliary obstruction – 胆道梗阻
2. Gall bladder obstruction – 胆囊梗阻
3. Hepatitis B – B型肝炎
4. Hepatitis C – C型肝炎
5. Jaundice – 黄疸病
6. Pancreatitis – 胰腺炎
7. Other disease or disorder of the liver, gall bladder, biliary system or pancreas – 肝脏、胆囊、胆道系统或胰腺的其他疾病或病症
   

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8. Gallstone – 胆结石
9. Biliary stone – 胆结石 (肝内）
   Less than 1 years
   More than 1 years
   Operation done and fully recovered – 手术已完成，完全康复
   Operation done and not fully recovered – 手术已完成，但尚未完全康复
   No operation done and fully recovered – 没有进行手术，完全康复
   No operation done and not fully recovered – 没有进行手术，且尚未完全康复

Kidney or urinary system stones, kidney infection, polycystic kidneys, protein or blood in urine or any disease or disorder of the kidney, ureter, bladder, urethra, prostate or genital organs?

肾病或 泌尿系统生石，肾感染，多囊性肾，尿蛋白质或尿血或关于肾，输尿管，膀胱，尿道，前列腺，生殖器官的问题

IF YES

1. Blood in urine – 尿有血
2. Kidney infection – 肾感染
3. Polycystic kidneys – 多囊性肾
4. Protein in urine – 尿有蛋白质
5. Other disease or disorder of the kidney, ureter, bladder, urethra, prostate or genital organs
   其他关于肾，输尿管，膀胱，尿道，前列腺，生殖器官的问题
   

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6. Kidney/ urinary bladder stones – Single episode – 肾/膀胱结石 – 单次发作
7. Kidney/ urinary bladder stones – multiple episode – 肾/膀胱结石 – 多次发作
   Less than 3 years
   More than 3 years
   Operation done and fully recovered – 手术已完成，完全康复
   Operation done and not fully recovered – 手术已完成，但尚未完全康复
   No operation done and fully recovered – 没有进行手术，完全康复
   No operation done and not fully recovered – 没有进行手术，且尚未完全康复

Cancer, tumour, cyst, lump, growth, lymphoma, leukaemia, melanoma, Hodgkin’s disease, bone marrow disorders, any malignant or pre-malignant condition?

癌症，肿瘤，水瘤，肿块，长瘤，淋巴瘤，白血病，黑素瘤，淋巴肉芽肿病，骨髓非常，或任何已恶化中或恶化前？

IF YES

1. Bone marrow disorders 骨髓疾病
2. Cancer 癌症
3. Cysts 水瘤
4. Growth 长瘤
5. Hodgkin’s disease 淋巴肉芽肿病
6. Leukaemia 白血病
7. Lump 肿块
8. Lymphoma 淋巴瘤
9. Melanoma 黑素瘤
10. Tumour 肿瘤
11. Other malignant or pre-malignant condition 其他恶性或癌前病变

Blindness, cataract, glaucoma, impaired sight (excluding long sighted and short sighted), impaired hearing or speech, deafness, tonsillitis, deviated nasal septum, chronic rhinitis, sinusitis, nose bleed, sleep apnoea or other disease or disorder of the eyes, ears, throat, mouth or nose?

失明，白内障，青光眼，视力减退(不包括远视和近视)，听力和说话能力减退，耳聋，扁桃体炎，鼻中隔偏曲，慢性鼻炎，鼻窦炎，鼻出血，睡眠呼吸暂停或任何关于眼睛，耳朵，喉咙，嘴巴或鼻子问题？

IF YES

1. Blindness – 失明
2. Chronic rhinitis – 慢性鼻炎
3. Deafness – 耳聋
4. Glaucoma – 青光眼
5. Impaired hearing – 听力障碍
6. Impaired sight (excluding long sighted and short sighted) – 视力障碍 (不包括远视和近视）
7. Impaired speech – 说话障碍
8. Nose bleed – 流鼻血
9. Sleep apnoea – 睡眠呼吸暂停
10. Other disease or disorder of the eyes, ears, throat, mouth or nose
    任何关于眼睛，耳朵，喉咙，嘴巴或鼻子问题

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11. Tonsillitis/Tonsils Inflammation – 扁桃体炎/扁桃体炎症
12. Deviated nasal septum (DNS) – 鼻中隔偏曲
13. Sinusitis/ sinus infection – 鼻窦炎/鼻窦感染
      Operation done and fully recovered with no recurrence
      手术已完成，已完全康复，未再复发
      Operation done and not fully recovered
      手术已完成，但尚未完全康复
      No operation done and fully recovered (without symtoms and not on treatment)
      没有进行手术，完全康复，没有症状并且没有在接受治疗。
      No operation done and not fully recovered
      没有进行手术，且尚未完全康复。
    

    ---

14. Cataract – 白内障
      Less than 1 years
      More than 1 years

      Operation done and fully recovered with normal vision and no recurrence
      手术完成，完全康复，视力正常，无复发
      Operation done and not fully recovered
      手术已完成，但尚未完全康复
      No operation done and fully recovered with no recurrence
      未做过手术，完全康复，未复发
      No operation done and not fully recovered
      没有进行手术，且尚未完全康复

Backache, slipped disc, spondylosis, arthritis, rheumatoid arthritis, systemic lupus erythomatosus (SLE), osteoporosis, gout, psoriasis, chronic skin disease or other disease or disorder of the immune system, connective tissue, spine, muscle, bone or joint?

背痛，椎间盘膨出，椎关节强硬，关节炎，类风湿性关节炎，系统性红斑狼疮，骨质疏松症，痛风, 牛皮癣，慢性皮肤病或任何关于免疫系统，结缔组织，脊椎，肌肉，骨骼或关节的问题？

IF YES

1. Backache – 背痛
2. Chronic skin disease – 慢性皮肤病
3. Gout – 痛风
4. Osteoporosis – 骨质疏松症
5. Psoriasis – 牛皮癣
6. Rheumatoid arthritis – 类风湿关节炎
7. Slipped disc – 椎间盘膨出(骨刺）
8. Spondylosis – 椎关节退化
9. Systemic lupus erythomatosus (SLE) – 红斑狼疮
10. Other disease or disorder of the immune system, connective tissue, spine, muscle, bone or joint
    关于免疫系统，结缔组织，脊椎，肌肉，骨骼或关节的问题

Syphilis, gonorrhea, venereal disease, Human Papilloma Virus (HPV) infection or any other sexually transmitted disease?

梅毒，淋病，花柳病，人类乳头状瘤病毒感染或任何关于性传播疾病的问题？

IF YES

1. Gonorrhea – 淋病
2. Human Papilloma Virus (HPV) infection – 人类乳头状瘤病毒感染
3. Syphilis – 梅毒
4. Venereal disease – 花柳病
5. Other sexually transmitted disease – 任何关于性传播疾病的问题

Any other illness, disease, disorder, disability, accident or hospitalization or any surgical operation or observation or treatment not of a routine nature that has not been mentioned above?

是否有其他的患病、疾病、不适、残缺、意外事件、住院记录、任何手术、病况观察、医疗疗程，或非天生、非自然或以上没提出的状况？

IF YES

1. Acute Gastroenteritis(AGE)/ food poisoning- Multiple episode
   急性胃肠炎（AGE）/食物中毒-多次发作
2. Fever (viral fever/ high fever)- Multiple episode
   发烧（病毒性发烧/高烧）- 多次发作
3. Accidental injuries – 意外伤害
4. Other- 其他

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5. Acute Gastroenteritis(AGE)/ food poisoning- Single episode
   急性胃肠炎（AGE）/食物中毒-单次发作
6. Fever (viral fever/ high fever) – Single episode
   发烧（病毒性发烧/高烧）- 单次发作
7. Dengue Fever – 登革热
   Hospitalised and fully recovered – 住院并完全康复
   Hospitalised and not fully recovered – 住院且尚未完全康复
   Not hospitalised and fully recovered – 没有住院并完全康复
   Not hospitalised and not fully recovered – 未住院且未完全康复

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8. Appendicitis – 割盲肠
   Operation done and fully recovered – 手术完成并完全康复
   Operation done and not fully recovered – 手术已完成但未完全恢复
   No operation done and fully recovered – 未做任何手术但完全康复
   No operation done and not fully recovered – 未做过手术且未完全恢复
   

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9. Hand Foot Mouth Disease – 手足口症
   Less than 6 months
   More than 6 months
   Hospitalised and fully recovered – 住院并完全康复
   Hospitalised and not fully recovered – 住院且尚未完全康复
   Not hospitalised and fully recovered – 没有住院并完全康复
   Not hospitalised and not fully recovered – 未住院且未完全康复
   

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10. Accidental injuries – Abrasion/ Laceration/ Sprain
    意外伤害 – 擦伤/撕裂/扭伤
    No admission and fully recovered – 无需入院并完全康复
    Other – 其他
    

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11. Accidental injuries – Fracture with no implant (exclude back, neck or skull)
    意外伤害 – 无植入物的骨折（不包括背部、颈部或头骨）
    – No admission and fully recovered without complications and/or residuals
    无需入院并完全康复，无并发症和/或残留
    Other – 其他
    

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12. Accidental injuries – Fracture with implant/internal fixation/plating (exclude back, neck or skull)
    意外伤害 – 植入物/内固定/钢板骨折（不包括背部、颈部或颅骨）
    Implant removed and without complications and/or residuals – 植入物已取出且 无并发症和/或残留
    Implant removed and with complications and/or residuals – 植入物被移除并 出现并发症和/或残留
    Implant not removed and without complications and/or residuals – 植入物未移除且 无并发症和/或残留物
    Implant not removed and with complications and/or residuals – 植入物未移除且 有并发症和/或残留
    

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13. COVID-19 Infection

    Presently tested positive for COVID-19 infection, with or without signs and symptoms (using antigen self-tests or Polymerase Chain Reactio- PCR test)
    目前 COVID-19 感染检测呈阳性，有或没有体征和症状（使用抗原自检或聚合酶链反应 PCR 检测）

    History of COVID-19 infection without admission, fully recovery without complications after the end of period of isolation/quarantine
    有感染 COVID-19 但未住过院，隔离/检疫期结束后完全康复且无并发症

    History of COVID-19 infection without admission, not fully recovery and/or with residual complications after the end of period of isolation/quarantine
    有感染 COVID-19 但未住过院、未完全康复和/或隔离/检疫期结束后有残留并发症

    History of COVID-19 infection with admission, full recovery without complications
    有因 COVID-19 住过院完全康复，无并发症

    History of COVID-19 infection with admission, without complete resolution of symtoms or not fully recovered and/or with residual complications
    有因 COVID-19 住过院，症状未完全缓解或未完全康复和/或有残留并发症

Have you or your spouse ever been tested for or received medical advice, counselling or treatment in connection with AIDS or infection with any Human Immunodeficiency Virus (HIV)？

您或您配偶是否曾经检验或接受关于HIV的医疗建议或疗程？

Is there anything in your lifestyle that puts you at an increased risk of AIDS or an AIDS related condition?

您的生活素质是否有让你提高接触或间接得到爱滋病风险？

Have you or your spouse in the past three months, suffered from any of the following for a continuous period of more than one week:-fatigue, weight loss, diarrhoea, enlarged lymph nodes or unusual skin lesions?

您或您配偶在过去的三个月，是否有感觉持续性一个星期或以上会感觉容易疲劳、体重减、腹泻、淋巴肿大或非寻常的皮肤损伤？

Have you ever resided for more than one continuous month in any country other than Malaysia for the past 1 year or do you intend to reside outside Malaysia for purposes other than brief holiday trips in the next 3 months?
If “YES”, please state name of country and purpose of residence below.

您在过去的一年内，是否有在非马来西亚以外的国家居留持续超过一个月，或在未来的三个月内除了旅游，是否有计划出外国居留？
如”YES”，请列出您将计划要去居留的国家名和原因。

IF YES

Country of Residence – 居住国家：________

Reason Abroad – 出国理由:
a. Working overseas
b. Studying overseas
c. Others:_______

&

Reside with – 与 一起居住:
a. Family
b. Spouse
c. Others:_______

Have you ever engaged or do you contemplate to engage in any of the following pursuits: Aviation, parachuting, motor sports, diving, mountaineering, or any other dangerous sports?
If “YES”, please give full details.

您是否有意从事或打算参加以下任何的事项航空业，跳伞，赛车运动，跳水，登山或任何的高危运动？
如”YES”,请详细列出有关详情。

IF YES

1. Aviation – 航空
2. Diving – 潜水
3. Motor Sports – 赛车运动
4. Mountaineering – 登山
5. Parachuting – 跳伞
6. Other dangerous sports – 其他危险运动

In the past 5 years, have you ever had or been advised or intend to undergo any investigation or screening test including but not limited to blood or urine test, pap smear, mammogram, ultrasound, biopsy, X-ray, CT scan, MRI, ECG, treadmill ECG, echocardiogram, lung function test, bone density test, angiogram, scope, EEG, Sleep study?

在过去的五年内，您是否有被建议或特地去做深入检测或检视的测验，包括（如有）血或尿的检验，宫颈刮片，乳房X光检查，超声波，活组织检查，X光，断层扫描，核磁共振成像，心电图，跑步心电图，超声心电图，肺功能检测，骨密度检测，血管造影片，局部检测，脑电图，睡眠监测系统?

IF YES

Check-up Items – 检查项目

1. Blood Test – 验血
2. Urine Test – 尿检
3. ECG – 心电图
4. Treadmill ECG – 跑步机心电图
5. X-ray – X射线
6. Pap smear – 子宫颈抹片检查
7. Mammogram – 乳房X光检查
8. Ultrasound – 超声波
9. Biopsy – 活检
10. CT Scan – CT 扫描
11. Echocardiogram – 超声心动图
12. MRI – 核磁共振成像
13. Lung function test – 肺功能检查
14. Scope – 体检内窥
15. Angiogram – 血管造影
16. EEG – 脑电图
17. Bone density – 骨密度
18. Sleep study – 睡眠研究

    ---

Reason For Check-up – 体检原因

1. Health Conscious – 健康意识
2. Routine Medical Check Up – 常规体检
3. University Entrance – 大学入学
4. Pre-employment / Employment Check Up – 就业前/就业检查
5. License Renewal – 执照更新
6. Working / Student Visa Application – 工作/学生签证申请
7. Working Permit for Singapore – 新加坡工作许可证
8. Working Permit for Brunei – 文莱工作许可证
9. Pregnancy Check Up / Delivery of Baby – 怀孕检查/分娩
10. Routine baby check up and vaccination – 婴儿常规检查和疫苗接种
11. Others – 其他

How long has the check up report been – 体检报告有多久了

1. Less than 6 months
2. More than 6 months

How was the result – 体检报告成绩如何

1. Normal – 正常
2. Abnormal – 不正常

Are you pregnant?          ___month

您目前有怀孕吗？

Have you ever had any complications in current or previous pregnancy or childbirth (e.g. gestational diabetes, gestational hypertension, preeclampsia/eclampsia, ectopic pregnancy, stillbirth, miscarriage, disseminated intravascular coagulation, placental abruption, amniotic fluid embolism, therapeutic abortion, caesarean section due to underlying medical condition, cervical insufficiency, fetus abnormalities, Rh Disease or acute infections)?

您在当前或以前的妊娠或分娩过程中是否有任何并发症（如妊娠糖尿病、妊娠高血压、异位妊娠、死产、流产、弥散性血管内凝血、胎盘早剥、羊水栓塞、治疗性流产、因基础疾病导致的剖宫产、宫颈机能不全、胎儿异常、Rh疾病或急性感染 ）？

IF YES

1. Caesarean Section – History with no complications or underlying medical condition
   剖腹产 – 无并发症或潜在健康状况的病史
2. Ectopic Pregnancy – History with no complications
   宫外孕 – 无并发症的病史
3. Stillbirth / Miscarriage – History with no complications
   死产/流产 – 无并发症的病史
4. Other Pregnancy or Childbirth Related Complications
   其他怀孕或分娩相关的并发症

Have you ever been or currently being informed, investigated, treated or advised to seek any medical or surgical treatment for breast lumps, fibroids, ovarian cysts, polycystic ovarian syndrome, endometriosis, cervicitis, abnormal papsmear(s), or any other disease or disorder of the breast or female organs?

你是否曾经或正在被告知，调查，处理或应寻求任何医疗或手术治疗关于乳房肿块，子宫肌瘤，卵巢囊肿，多囊卵巢综合征，子宫内膜异位，宫颈炎，异常的宫颈刮片，或任何关于乳房或女性器官的疾病？

IF YES

1. Abnormal papsmear(s) – 子宫颈抹片检查异常
2. Breast Lumps – 乳房肿块
3. Cervicitis – 宫颈炎
4. Endometriosis – 子宫内膜异位症
5. Fibroids – 肌瘤
6. Ovarian cysts – 卵巢囊肿
7. Polycystic ovarian syndrome – 多囊卵巢综合征
8. Other disease or disorder of the breast or female organs
   乳腺或女性器官的其他疾病或异常

Was the child born premature/less than 37 weeks of age?
If “YES”, please state gestational period: ___weeks and birth weight ___kg

小孩是足月出生或是少过37个星期(9.25个月)
如”YES”，不足月请填上多少星期和重量

Has the child ever been or currently being informed, investigated, treated or advised to seek any medical or surgical treatment for any complications at birth or in the first 30 days of life, prolonged neonatal jaundice requiring hospitalization, infection, breathing difficulty or lung disorder, G6PD deficiency, abnormal thyroid blood test, blood abnormalities, fits, congenital disorder or birth defects or developmental abnormalities, physical or mental impairment, hearing, eye-sight or speech impairment?

在孩子出世的30天内是否曾经或正在被告知，检查，治疗或建议寻求任何医疗或手术治疗于任何并发症，被要求进院新生儿黄疸期延长，感染，呼吸困难或肺部失常，G6PD缺乏症，异常甲状腺验血，血象异常，痉挛，先天性缺陷，发育不健全，身体或精神障碍，听觉，视力或声音障碍？

IF YES

1. Prolonged neonatal jaundice requiring hospitalization – 新生儿黄疸持续时间较长需住院治疗
2. Breathing difficulty or lung disorder – 呼吸困难或肺部失常
3. G6PD deficiency – G6PD缺乏症
4. Infection – 感染
5. Birth defects – 出生缺陷
6. Abnormal thyroid blood test – 异常甲状腺验血
7. Blood abnormalities – 血液异常
8. Fits – 癫痫
9. Congenital disorder – 先天性疾病
10. Developmental abnormalities – 发育异常
11. Physical impairment – 身体障碍
12. Mental impairment – 精神障碍
13. Hearing impairment – 听力障碍
14. Eye-sight impairment – 视力障碍
15. Speech impairment – 言语障碍

Are you currently a tax resident outside Malaysia?

您目前是马来西亚境外的税务居民吗？

IF YES

Country of Tax Residence: _______________
Tax Identification Number (TIN): _______________

Please select one of the BELOW reason if you are unable to provide the TIN:

1. The account holder is otherwise unable to obtain a TIN or equivalent number
   帐户持有人无法获得 TIN 或同等号码

If the country of your address or telephone number differs from your declared country of tax residency, please indicate only one of the BELOW following reasons:
如果您的地址或电话号码所在的国家/地区与您申报的税务居住国家/地区不同，请仅注明以下原因之一：

1. Student at an educational institution in the country of residential/ mailing address/ telephone numbers
   居住/邮寄地址/电话号码所在国家/地区教育机构的学生
2. Working in the country of residential/ mailing address/ telephone numbers for less than 6 months
   在居住/邮寄地址/电话号码所在国家/地区工作少于 6 个月
3. On an educational or cultural exchange visitor program in the country of residential/ mailing address/ telephone numbers for less than 6 months
   在居住/邮寄地址/电话号码所在国家/地区进行教育或文化交流访问计划，为期不超过 6 个月
4. Reqular travel between countries/ jurisdictions for work and home
   定期在国家/司法管辖区之间出差工作和回家