Patient Inquiry Form

    General Information

    First Name
    Last Name
    Age
    Date of Birth
    Gender MaleFemale
    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: YesNo
    Thyroid problems YesNo
    Heart problems YesNo
    Lung problems YesNo
    Blood pressure problems YesNo
    Kidney or Liver problems YesNo
    Blood disorders YesNo
    Previous/current history of cancer YesNo
    Do you have any medical
    conditions not mentioned above?
    Do you have any allergies to food, drugs, etc?
    Do you smoke? YesNo
    If yes, how much do you smoke?
    When did you last smoke?
    Do you drink alcohol? YesNo
    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?
    YesNo
    If yes, when was your last dose?

    For Women

    Do you take birth control pills, hormone replacement
    medication, or wear a hormone patch?
    YesNo
    Are you pregnant now? YesNo
    Are you planning any more pregnancies? YesNo
    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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