Pre-Check-up Health Assessment

This is the official health assessment required by your booked Tier 3A grade hospital before your check-up appointment. It takes about 8–12 minutes to complete and helps the medical team prepare appropriately for your visit.

Your information is confidential — reviewed by SinoCareLink medical coordinators and shared with the hospital you've booked for medical-safety purposes only. We do not share it with third parties.

If you'd prefer help filling it out, message us on WhatsApp and a coordinator will complete it with you over the phone.

Health Assessment

About 8–12 minutes · 50 questions · Your data stays confidential.

⚠ Some required questions need your attention. We've scrolled to the first one and highlighted it in pink below. Please fix and try again.

Section A · Patient Identity

Passport Name (English) *

Email *

Phone / WhatsApp *

Nationality *

Date of Birth *

Gender (Sex on Passport) *

Female Male

Passport No. (optional)

Your Booking Reference / Order Number (from Shopify order email)

Passport photo / scan (optional) (jpg/png/pdf, ≤8MB — optional now, speeds up booking later)

Section B · Background

Occupation *

IT/Electronics Finance/Insurance Trade Real Estate/Construction Transport/Logistics Healthcare Education/Training Catering/Hotel Media/Culture/Sports Government Energy/Mining/Environment Manufacturing Agriculture/Forestry/Fishery Other

Highest Education *

Primary or below Secondary Associate (College) Bachelor Master PhD

Marital Status *

Single Co-living Married Separated Divorced Widowed

Section C · Medical History

1. Drug allergies *

No Yes Click Yes to choose which drug(s)

Which drugs? (tick all that apply)

Penicillin Streptomycin Cephalosporin Procaine Tetanus serum Mycostatin Alcohol Sulfonamides

Other (please specify)

2. Have you ever been diagnosed with any of the following? *

No Yes Click Yes to see 18 conditions (hypertension, diabetes, cancer, etc.)

Please tick all that apply and provide age at diagnosis:

Hypertension

Age at diagnosis:

Elevated blood pressure

Age at diagnosis:

Diabetes

Age at diagnosis:

Elevated blood sugar

Age at diagnosis:

Hyperlipidemia (high cholesterol)

Age at diagnosis:

Fracture

Age at diagnosis: Location:

Coronary heart disease

Age at diagnosis:

Anemia

Age at diagnosis: Type:

Thyroid nodule

Age at diagnosis:

Thyroid disease

Age at diagnosis: Type:

Hep B carrier

Age at diagnosis:

Chronic Hep B

Age at diagnosis:

Hep C carrier

Age at diagnosis:

Chronic Hep C

Age at diagnosis:

Tuberculosis

Age at diagnosis: Site:

Cancer

Age at diagnosis: Site:

Surgery history

Age at diagnosis: Type:

Gynecological disease

Age at diagnosis: Site / type:

Other diagnosed condition (please specify name + age at diagnosis)

3. Have you taken any medication in the past month? *

No Not sure Yes Click Yes to choose which medication(s)

Which medications? (tick all that apply)

Amoxicillin Atorvastatin Rosuvastatin Fenofibrate Nifedipine Valsartan + Amlodipine Metoprolol succinate Metformin HCl Acarbose Insulin Febuxostat Allopurinol Benzbromarone Cephalosporins

Other medications (please specify name + dose if known)

4. How often do you exercise? *

Regularly Occasionally (<1/week) Rarely / Never

Average minutes per week (when you do exercise)

5. Smoking *

Never Occasionally (<7/week) Current Former

6. Alcohol *

Never Occasionally (<1/week) Current

7. Workday screen time (leisure) *

<2h/day 2–4h/day 4–6h/day 6–8h/day >8h/day

8. Rest-day screen time (leisure) *

<2h/day 2–4h/day 4–6h/day 6–8h/day >8h/day

9. Frequency of using a screen within 1 hour before sleep *

Every day 5–6 days/week 3–4 days/week 1–2 days/week Never

10. Hours/week of moderate exercise (brisk walking, cycling, swimming, cleaning)

11. Hours/workday of sitting (desk, TV, driving — exclude sleep)

Section D · Sleep Assessment

1. Difficulty falling asleep *

None Mild Moderate Severe Very severe

2. Difficulty maintaining sleep (waking at night) *

None Mild Moderate Severe Very severe

3. Early-morning awakening *

None Mild Moderate Severe Very severe

4. Satisfaction with your sleep in the past 2 weeks *

Very satisfied Satisfied Moderately Unsatisfied Very unsatisfied

5. How much do sleep problems affect your work, attention, mood? *

None Slight Moderate Noticeable Very noticeable

6. From others' view (family/friends), does your sleep problem reduce your quality of life? *

None Slight Moderate Noticeable Very noticeable

7. How worried/distressed are you about your sleep problem? *

None Slight Moderate Noticeable Very noticeable

Avg sleep hours on workdays *

Avg sleep hours on rest days *

Section E · Mood (last 2 weeks)

1. Little interest or pleasure in doing things *

Not at all Several days More than half the days Nearly every day

2. Feeling down, depressed, or hopeless *

Not at all Several days More than half the days Nearly every day

Section F · Family History

Has any first-degree relative (parents / siblings / children) been diagnosed with the following? *

No Yes Click Yes to see 7 inherited conditions (hypertension, diabetes, cancer, etc.)

Please tick all that apply:

Hypertension Diabetes High cholesterol Hepatitis B/C carrier Coronary heart disease Tuberculosis Cancer

Other family conditions (please specify relationship + condition)

Section G · Urinary Function (past 3 months)

Have you experienced any urinary leakage in the past 3 months? *

No Yes Click Yes to choose when it happens

Please tick all that apply:

On cough, sneeze, lifting, or exercise (stress incontinence) Urgent need but can't reach toilet, without abdominal pressure (urge incontinence) Mixed: pressure and urgency together (mixed incontinence)

Section H · Additional Notes

Anything else our medical coordinator should know? (symptoms, special concerns, dietary needs, mobility issues)

I confirm the information provided above is accurate to the best of my knowledge. I authorize SinoCareLink medical coordinators to share these details with the booked hospital strictly for medical safety and screening planning purposes. Data is stored encrypted in Singapore, retained for up to 5 years from my last interaction, and processed under the SinoCareLink Privacy Policy. I may contact info@sinocarelink.org at any time to request deletion, export, or correction. *

本人确认以上信息真实有效，并授权 SinoCareLink 医疗协调团队仅为医疗安全及体检规划目的向预约医院提供本人数据。数据以加密形式托管于新加坡，自最后一次互动起保留至多 5 年，依据 SinoCareLink 隐私政策处理。本人可随时联系 info@sinocarelink.org 行使删除、导出或更正权利。

🔒 Reviewed only by SinoCareLink medical coordinators. Forwarded to the hospital you've booked with — never to third parties.

Need help completing this form?

Some sections are detailed — especially the medical history. If anything is unclear, message us on WhatsApp and we'll walk through it with you.

Message Us on WhatsApp

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