| Name | Date | |
|---|---|---|
| Gender: ▢ Male ▢ Female ▢ Other: | Age: | |
| Highest educational level: | ▢ None ▢ Elementary ▢ Junior high ▢ Senior high ▢ Collage ▢ Graduate school | |
| Chronic underlying disease: (Multiple choice) | ▢ Hypertension ▢ Diabetes mellitus ▢ Valvular heart disease ▢ Coronary artery disease ▢ Renal disease ▢ Stroke ▢ Hemodialysis/ Peritoneal dialysis ▢ Hepatitis ▢ Affective disorders ▢ Gastrointestinal ulcer ▢ Cancer history ▢ Others: | |
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