Please fill in the form below with your information.

1. Full Name: __________

2. How do you feel today?
☐ I feel well
☐ I don’t feel well

3. What symptoms do you have? (Check all that apply)
☐ Stomachache
☐ Fever
☐ Diarrhea
☐ Cough
☐ Headache
☐ Other: ___________________________

4. What is your height?
_________ cm or meters

5. What is your weight?
_________ kg

6. Do you have diarrhea?
☐ Yes
☐ No

7. Do you have a high temperature?
☐ Yes
☐ No
☐ I don’t know

8. Have you had your blood pressure checked yet?
☐ Yes
☐ No

Instructions:
Listen to the conversation and fill in the missing words.

Receptionist: Good morning! Welcome to City General ______.
Patient: Good ______.
Receptionist: How may I ______ you?
Patient: I don’t feel well. I have a ______ and a ______.
Receptionist: I’m sorry to hear that. What ______ you here today?
Patient: My stomach is ______, and I think I have a high ______.
Receptionist: Okay. Now I will send you to a ______.
Patient: Thank you.
Receptionist: Please go over there to have your ______ pressure checked.

Nurse: Hello! Before you see the doctor, I need to check a few ______.
How ______ are you?
Patient: I’m 1 meter 70 centimeters ______.
Nurse: What is your ______?
Patient: I weigh 65 ______.
Nurse: Do you have ______?
Patient: No, just a stomachache and a ______.
Nurse: Okay, thank you. You may now go to the doctor’s ______.