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 medicalconditions 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 currentlytake including dosage for each Have you ever taken an anticoagulant such asCoumadin, Heparin, or a daily Aspirin? Yes No If yes, when was your last dose? For Women Do you take birth control pills, hormone replacementmedication, 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. Input this code:
