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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