Patient Application

BIO DATA
Name :
(On your Passport)
Preferred Name :
(Nick Name)
Telephone :   Fax. :
E-mail :
Birthday :
Weight : Pound. Kg.
Height : Feet. Cm.
Nationality :
Address :
City :
State :
Country :
zipcode :
Passport Number :

Surgical Information
Select desired service procedure
Facial Feminization Surgery (FFS)

Upper Eyelid Surgery
Lower Eyelid Surgery
Full Face Lift
Mini Face Lift
Forehead Lift
Nose Augmentation
Nose Reduction
Alaplasty

 Cheek Bone Contouring
Cheek Augmentation
Chin Augmentation
Chin Shaving
Ear Surgery
Botox Injection
Tip Rhinoplasty
Facial Feminization Surgery

Breast

Breast Augmentation
Breast Reduction

 Breast Lift

Sex Reassignment Surgery (SRS)

Male to Female
Sigmoid Colon

 Bilateral Orchiectomy (BO)
Reconstruction of SRS

Body Contouring

Liposuction
Lipectomy

 Adam's Apple Contouring
Fat Injection


Other service procedure :
Request Date of Operation :
To :
 

In case of an emergency, Notify:

Name :
Relationship : E-mail address :
Telephone : Fax. :
 
Address in Thailand, or office address :
Telephone : Fax. :
 
Referred by :
Is it okay with you to send a thank you note to the person who referred you to us ?
Yes , E-mail Address :
No

Allergies:

Yes (Please list below) No
Importance : Please inform us about your Allergies or Unfavorable Reactions to any Medications or Substances. (Please List)

Your Accommodation:
Please inform us about your accommodation.
At the hospital
At hotel as I choose
 

Health History
Have you had, or do you still have :
1) Cold or Cough within the last two weeks Yes No
2) Breathing Problems (Asthma, etc.) Yes No
3) Chest Pains or Angina Yes No
4) Heart Problems Yes No
5) Palpitations, Irregular or Fast heart beat Yes No
6) Shortness of Breath at any time Yes No
7) High blood pressure Yes No
8) Any Circulatory Problems Yes No
9) Blood Disease (Anemia, etc.) Yes No
10) Bleeding Problems Yes No
11) Any Immune Problems Or Disease Yes No
12) Liver Disease (Hepatitis, Jaundice, etc.) Yes No
13) Stomach Problems (Ulcers, etc.) Yes No
14) Intestinal Problems Yes No
15) Neck or Back pain or Injuries Yes No

16) Seizures
      Years

Yes Yes
17) Headaches Yes Yes
18) Stroke or Temporary Paralysis Yes Yes
19) Psychiatric or Psychological Treatment Yes Yes
20) Any Visual or Eye Problems (Dryness, etc.) Yes Yes
21) Glasss or Contact Lenses Yes No
22) Diabetes Yes No
23) Thyroid Problems Yes No
24) Kidney or Bladder Problems Yes Yes
25) Any Problems during Pregnancy Yes Yes
26) Problems with Alcohol or Drug abuse Yes Yes
27) Weight change in the past year Yes No
28) Connective tissue disease (Lupus, Pheumaoid Arthritis, Scleroderma, etc.) Yes No
29) Cold Sores or Other Herpes Infections Yes Yes
30) Change in any skin growth (Moles, etc.) Yes Yes
31) Cancer of any type Yes No
32) Surgery (Please list type and Dates) Include all Cosmetic Surgery
       		Yes Yes
33) How many year have you been on hormones? Yes Yes
34) Any mecication or pills within 3 years (Please list)
       		Yes Yes
35) Do you take Aspirin, Advil or Other anti-Inflammatory Medications Yes No
36) Have you ever smoked
       How much per day
      If you've quit, When

Yes Yes
37) Do you drink alcohol     
      How much per week 		Yes Yes
38) When was your last physical exam Yes Yes
39) When was your last menstrual period Yes Yes
40) Have you been told you have any other diseases not mentioned above? If yes, please list them :
       		Yes No
 
I authorize you to give me reasonable & proper medical care by today´s standards. I, the patient or responsible party, authorize release of medical information for the purpose of processing medical claims.
 
 

Sex Reassignment Surgery (SRS)
   + Male to Female
   + Sigmoid Colon
Breast
   + Breast Augmentation
   + Breast Reduction
   + Breast Lift
Facial Feminization Surgery (FFS)
   + Upper Eyelid Surgery
   + Lower Eyelid Surgery
   + Full Face Lift
   + Mini Face Lift
   + Forehead Lift
   + Nose Augmentation
   + Nose Reduction
   + Alaplasty
   + Cheek Bone Contouring
   + Cheek Augmentation
   + Chin Augmentation
   + Chin Shaving
   + Ear Surgery
   + Botox Injection
   + Tip Rhinoplasty
   + Facial Feminization Surgery
Body Contouring
   + Liposuction
   + Lipectomy
   + Adam's Apple Contouring
   + Fat Injection
Resources
   + FAQ
   + Photo Gallery
   + Link Directory
   + Useful Links
   + Glossary
   + Sex change surgery
Hospital Affiliation
   + ChareonkrungPracharak Hospital
   + Bangkok Nursing Home Hospital
   + Bumrungrad Hospital
   + Piyavate Hopsital
Customer Tools
   + Thailand Guide
   + Language Translator
   + Currency Convertor
   + Weather
   + World Time