คลินิกเวชกรรม สวท Basic InformationTitle(Required)Please selectMissMrs.ChildDr.name(Required) Lastname(Required) Mobile Number(Required) HiddenSexFemaleHiddenpmseu4HiddenEmail Passport(Required)Please selectID CardPassport No.NoPassport No. DOB(Required)DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required) Basic informationWeight(Required) Height(Required) Education(Required)Please selectPrimary SchoolSecondary SchoolHigh SchoolDiploma DegreeHigh Diploma DegreeBachelor DegreesUpper than Bachelor Degreesoccupation(Required)Please selectFarmergovernment officertradefishermanpersonal businessstudentscompany employeestate enterprise employeesmaidgeneral employeegovernment employeesunemployedmarital status(Required)Please selectsinglemarrieddivorced/separatedothernationality(Required)Please selectThaiMyanmarCambodiaLaosVietnamChinaotheraddress for drug deliveryregion(Required)Region of current residencethe NorthNortheastCentralEasternwestern regionSouthabroadcurrent address(Required) district(Required) district(Required) province(Required) zip code(Required) Emergency Contactcontact name(Required) Contact's last name(Required) Mobile Number(Required) medical informationDo you have a history of drug allergies?(Required)Please selectdo not havehavea history of drug allergies(Required) health history and regular medications(Required) How many times is it a pregnancy?(Required)Please select1st time2nd time3rd time4th time5th timehaving children included(Required)Please selectdo not have1 person2 people3 people4 people5 peoplemore than 5 peopleYoungest child age (years)(Required)(month)(Required)being a woman (person)(Required)Please select0 people1 person2 people3 people4 people5 peoplemore than 5 peoplemale (person)(Required)Please select0 people1 person2 people3 people4 people5 peoplemore than 5 peoplemethod of childbirth(Required)Please selectnatural birthCaesarean sectionever had an ectopic pregnancyHave you had a miscarriage before?(Required) ever never How many times have you had an abortion?(Required)Please select1 time2 times3 times4 times5 timesHow is it a miscarriage?(Required)Please selectspontaneous abortionSafe AbortionSpontaneous abortion and termination of pregnancyWhat is your gestational age (weeks)?(Required)Please select4 to 12 weeksmore than 12 weeksMore than 12 weeks (please specify gestational age)(Required) cause of pregnancy(Required)Please selectcontraceptive failureUsing emergency contraceptives was raped.count the days wrongnot contraceptiveforget to take birth control pillscum outsideotherOther reasons, please specify.(Required) The reason for the termination of pregnancy is(Required)Please selectPregnancy is a career hurdle.family problemsPregnant with someone who is not your husbandrapedfinancial problemshealth problemsThe man has a familymen are not responsiblehaving too many childrenhaving enough childrenhaving problems with male relativeshave a new husbandunmarriednot yet graduatedDivorce or break up with husband or male friendotherOther reasons, please specify.(Required) Confirm Service(Required) Please click to confirm the service and accept all terms and conditions from PPAT Telemed system. 439 total views, 1 views today