Oops! It appears that you have disabled your Javascript. In order for you to see this page as it is meant to appear, we ask that you please re-enable your Javascript!

HEALTH INQUIRY FORM / BORANG PENYELIDIKAN KESIHATAN

Share

HEALTH INQUIRY FORM / BORANG PENYELIDIKAN KESIHATAN
* Required
Name / Nama penuh *
Give your full name / Sila beri nama penuh anda
Your answer
Nickname *
Your short name / Nama pendek anda
Your answer
Telephone Number/ No.Telefon *
Give your active contact number / Sila masukkan nombor yang mudah untuk kami hubungi
Your answer
Where did you get this information ? / Dari mana anda mendapat maklumat tentang kami ? *
please provide your friend's name or his/her social account / Sila berikan nama rakan anda atau akaun media sosialnya
Your answer
Occupation / Pekerjaan *
Your answer
E-mail/ E-mel *
Your answer
Convenient contact time/ Masa lapang untuk dihubungi *
Please choose your convenient time to answer the call / sila pilih waktu yang mudah untuk anda menjawab panggilan kami
Required
Skype account or Line ID or Wechat ID /Akaun Skype atau ID Line atau Wechat ID *
Your answer
Facebook acc / Akaun Facebook *
Your answer
State / Negeri *
please fill up with your district and country / sila isi beserta daerah dan negara
Your answer
Height/Tinggi *
in cm / dalam cm
Your answer
Weight/Berat *
in kg / dalam kg
Your answer
Fat percent / Peratus lemak (%)
skip if you did not know your fat percent / kosongkan jika anda tidak tahu peratus lemak anda
Your answer
Birthday/ tarikh lahir (yyyy / mm / yy) *
Your answer
How many kg that you want to lose/gain ? / Berapa banyakkah berat yang anda ingin turunkan/naikkan ? *
in kg
Your answer
Why do you think you are too fat or too thin ? / Mengapakah anda terlalu gemuk atau terlalu kurus ? *
ex:overeating,loss of appetite / kerana terlebih makan, selepas bersalin, hilang selera makan...
Your answer
Is it the way you've been doing to lose weight? / Apakah cara yang telah anda lakukan untuk mengurangkan berat badan ? *
ex: acupuncture, exercise, diet, medicine / senaman,diet,akupuntur,ubat tambahan
Your answer
Why you want to change ? / Mengapa anda ingin berubah ? *
because... people always insulting me / kerana orang ramai sering menghina saya ..
Your answer
Do you think you really serious to change your fate ?/ Adakah anda benar benar serius untuk mengubah nasib anda? *
Still confuse/ Masih dalam dilema
Very serious/ Benar benar serius
Constipation problem? Difficult to defecation everyday ? / menghadapi masalah sembelit atau susah untuk membuang air besar setiap hari ? *
Your answer
How many litres you drink per day ? /Berapa litre air kosong yang diminum pada setiap hari ? * *
coffee,soup,tea are not included / kopi teh dan sup tidak termasuk
Your answer
Your food criteria / Citarasa makanan anda *
Do you take any other food supplement ? / adakah anda mengambil makanan tambahan ? *
state type of supplement / nyatakan jenis ubat dan kegunaanya
Your answer
How often you sleep after 12 am ? / Berapa kerap anda tidur selepas pukul 12 tengah malam ? *
Required
Does your family will be denied if you follow our program? / Adakah keluarga anda akan membantah jika anda mengikuti program kami ? *
Your health ? *
Required
Your daily food menu ?/ Menu makanan harian anda? *
how many times do you eat everyday ? / berapa kali anda makan untuhk sehari ?
Your answer
What is your daily expenses to buy food? /Berapakah perbelanjaan harian anda untuk membeli makanan ? *
for ex: RM7 + RM5 + RM6 + 20 = RM38 for breakfast, lunch, tea, dinner / contoh : RM7+RM5+RM6+20 = RM38 untuk breakfast,lunch,tea,dinner
Your answer
If this is the last time you lose weight, how long you want to spend the time to lose weight ? /Jika ini adalah kali terakhir untuk anda mengurangkan berat badan, berapa tempohkah yang anda inginkan untuk mencapai impian anda? * *
Budget your expenses for a month? / Bajet perbelanjaan untuk sebulan ? *
excluding water bills, house rent, car money. State the amount you can afford to provide for this program./tidak termasuk bil air, sewa rumah, duit kereta . Nyatakan jumlah yang mampu anda sediakan untuk program ini .
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service
 
 
https://www.gstatic.com/_/freebird/_/js/k=freebird.v.en.90mSj4VdA64.O/rt=j/d=1/rs=AMjVe6g3YImgipMeac5UhlrjyaOlIiBxlg/m=viewer_base

Share