Patient Inquiry Form

General Information

First Name
Last Name
Age
Date of Birth
Gender  Male Female
Height (cm)
Weight (kg)
Passport Number
Email
Phone
Address

In Case of Emergency

Name
Email
Phone
Address
Relationship to Patient

Surgery Details

Planned Date of Surgery
Date of Arrival in Bangkok
What procedures do you require?
What results do you expect?
(Please be as specific as possible)
Questions to Surgeon

Medical Conditions

Diabetes or blood sugar problem:  Yes No
Thyroid problems  Yes No
Heart problems  Yes No
Lung problems  Yes No
Blood pressure problems  Yes No
Kidney or Liver problems  Yes No
Blood disorders  Yes No
Previous/current history of cancer  Yes No
Do you have any medical
conditions not mentioned above?
Do you have any allergies to food, drugs, etc?
Do you smoke?  Yes No
If yes, how much do you smoke?
When did you last smoke?
Do you drink alcohol?  Yes No
If yes, how much do you drink?
List all medications you currently
take including dosage for each
Have you ever taken an anticoagulant such as
Coumadin, Heparin, or a daily Aspirin?
 Yes No
If yes, when was your last dose?

For Women

Do you take birth control pills, hormone replacement
medication, or wear a hormone patch?
 Yes No
Are you pregnant now?  Yes No
Are you planning any more pregnancies?  Yes No
When did you last deliver a baby?
(Month & Year)
When did you last breastfeed?
(Month & Year)

Attach Medical Documents

By sending this form, you acknowledged that you have truthfully completed this form and have not made any purposeful omissions.

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