绗崄绔?/p>
鑲ヨ儢涓庝綋閲嶆帶鍒?/p>
锛堜竴锛夊～绌洪
1.
浜轰綋鑴傝偑鍒嗕负
___________
鍜?/p>
___________
涓ょ銆?/p>
2.
鍌ㄥ瓨鑴傝偑涓昏浣滅敤鏄?/p>
_________
銆?/p>
__________________
鍙婅兘婧愬偍瀛樸�?/p>
3.
蹇呴渶鑴傝偑涓昏鐢ㄦ潵缁存寔姝ｅ父鐨勭敓鐞嗗姛鑳斤紝鍏剁害鍗犵敺鎬ф�讳綋閲嶇殑
________%
锛岀害鍗犲コ鎬ф�讳綋
閲嶇殑
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銆?/p>
4.
渚濈収鍙戠敓鍘熷洜锛岃偉鑳栧彲鍒嗕负
____________
鎬ц偉鑳栧拰
___________
鎬ц偉鑳栥�?/p>
5.
渚濈収鑴傝偑鍦ㄨ韩浣撲笉鍚岄儴浣嶇殑鍒嗗竷锛岃偉鑳栧彲鍒嗕负
___________
鍨嬭偉鑳栧拰
__________
鍨嬭偉鑳栥�?/p>
6.
渚濈収鑴傝偑鍦ㄨ韩浣撲笉鍚岄儴浣嶇殑鍒嗗竷锛岃偉鑳栧彲鍒嗕负涓ょ绫诲瀷锛屽叾涓敺鎬у涓?/p>
___________
鍨嬭偉
鑳栵紝鍏惰剛鑲富瑕佹矇绉湪
________________________
銆?/p>
7.
鏍规嵁浜轰綋鍚勭粍鎴愭垚鍒嗙殑鐢熺悊鍔熸晥涓嶅悓锛屽父鎶婁綋閲嶅垎涓?/p>
____________
鍜?/p>
___________
銆?/p>
8.
甯哥敤鐨勮偉鑳栬瘖鏂寚鏍囨湁鑲ヨ儢搴?/p>
%
銆?/p>
_________
銆?/p>
_________
鍜?/p>
____________
銆?/p>
9.
涓栫晫鍗敓缁勭粐
2002
骞撮拡瀵逛簹娲蹭汉鍒跺畾浜嗚偉鑳栫殑璇婃柇鎺ㄨ崘鏍囧噯锛?/p>
BMI
澶т簬
________(kg/m
2
)
涓鸿秴閲嶏紝澶т簬
_______ (kg/m
2
)
涓鸿偉鑳栥�?/p>
10.
鑵拌噣鍥存瘮鏄互鑴傝偑鍒嗗竷鏉ヨ瘎浠锋偅鐥呭嵄闄╁嚑鐜囩殑涓�绉嶇畝渚挎柟娉曪紝鑻ョ敺鎬х殑鑵拌噣鍥存瘮鍊艰秴杩?
________
锛屽コ鎬х殑鑵拌噣鍥存瘮鍊艰秴杩?/p>
________
锛屾偅鐥呯巼灏变細澶у箙搴﹀鍔犮�?/p>
11.
甯哥敤浜庤瘎浼颁綋鍔涙椿鍔ㄨ兘閲忔秷鑰楃殑鏂规硶鏈夊弻鏍囨按璇勪及娉曘�佽繍鍔ㄥ姞閫熷害鎰熷簲璁℃硶銆佺洿鎺ヨ瀵?
娉曘�?/p>
______________
銆?/p>
_______________
鍜?/p>
__________________
绛夋柟娉曘�?/p>
12.
娴嬮噺璇勪及浣撴垚鍒嗙殑鏂规硶寰堝锛屽叾涓毊瑜跺帤搴︽硶涓嶄粎鍙互鍙嶆槧浣撹剛鍒嗗竷鎯呭喌锛屼篃鍙互浠庤韩
浣撲笉鍚岄儴浣嶇殑浣撹剛鍒嗗竷鏉ユ帹绠椾綋鑴傛�婚噺銆?/p>
閲囩敤璇ユ柟娉曟祴閲忓洓鑲㈢毊涓嬭剛鑲垎甯冩椂锛?/p>
涓�鑸祴
閲?/p>
____________
鍜?/p>
_____________
绛夐儴浣嶃�?/p>
13.
閲囩敤
鐨ざ鍘氬害娉曟祴閲忚瘎
浼颁綋鎴愬垎鏃?/p>
锛屽コ鎬у父娴?/p>
閲?/p>
____________
銆?/p>
____________
鍜?
__________
绛夐儴浣嶃�?/p>
14.
閲囩敤鐨ざ鍘氬害娉曟祴閲忚瘎浼颁綋鎴愬垎鏃讹紝鐢锋�у父娴嬮噺
__________
銆?/p>
__________
鍜?/p>
_________
绛夐儴浣嶃�?/p>
15.
浜轰綋鑳介噺骞宠 鐘舵�佸垎涓?/p>
_____________
銆?/p>
_____________
鍜?/p>
_____________
涓夌銆?/p>
16.
浜?/p>
浣?/p>
姣?/p>
澶?/p>
鎵�
娑?/p>
鑰?/p>
鐨?/p>
鑳?/p>
閲?/p>
鍙?/p>
鍒?/p>
涓?/p>
______________________________
銆?
________________________
鍜?/p>
_____________________________
涓夐儴鍒嗐�?/p>
17.
浜轰綋瀹夐潤鏃舵墍娑堣�楃殑鑳介噺鍙垎涓轰笁閮ㄥ垎锛屽叾涓?/p>
____________
娑堣�楄兘閲忔渶澶氾紝鎵�鍗犳瘮鐜囦负
_______%
銆?/p>
18.
杩愬姩鍛樺噺浣撻噸甯哥敤鐨勬柟娉曟湁涓诲姩闄愬埗鑳介噺鎽勫叆銆佽嵂鐗╂姂鍒堕娆层�佸鍔犱綋鍔涙椿鍔ㄩ噺鍜?
___________
锛屽缓璁噺浣撻噸鏈�澶ч噺姣忓懆涓嶈秴杩?/p>
_______
鍏枻銆?/p>
19.
杩愬姩澶勬柟鍥涜绱犲寘鎷繍鍔ㄦ柟寮忋�?/p>
______________
銆?/p>
_______________
鍜?/p>
_____________
銆?/p>
20.
鍦?/p>
鍒?/p>
瀹?/p>
鍑?/p>
鑲?/p>
杩?/p>
鍔?/p>
澶?/p>
鏂?/p>
鏃?/p>
锛?/p>
搴?/p>
閬?/p>
寰?/p>
涓?/p>
鍒?/p>
鍘?/p>
鍒?/p>
锛?/p>
_______________
銆?/p>
_____________
鍜?
_____________
銆?/p>
21.
鍑忚偉杩愬姩閫氬父杩愬姩寮哄害涓?/p>
__________%
鏈�澶у績鐜囷紝
缁冧範棰戠巼涓?/p>
_________
娆?/p>
/
鍛紝
姣忔杩愬姩
鎸佺画鏃堕棿鑷冲皯
_______
鍒嗛挓銆?/p>
锛堜簩锛夊垽鏂
1.
缁у彂鎬ц偉鑳栦富瑕佷笌鐢熸椿鏂瑰紡瀵嗗垏鐩稿叧锛?/p>
浠ヨ繃搴﹁惀鍏汇�?/p>
杩愬姩涓嶈冻銆?/p>
蹇冪悊琛屼负鍋忓樊涓虹壒寰併�?/p>
锛?/p>
锛?/p>
2.
鑳介噺鏀嚭灏忎簬鎽勫叆涓鸿兘閲忚礋骞宠 銆?/p>
锛?/p>
锛?/p>
3.
閫氳繃杩愬姩鍑忚偉锛屽缓璁瘡鍛ㄤ綋閲嶄笅闄嶄互
1
鍏枻涓哄疁銆?/p>
锛?/p>
锛?/p>