Request Telemed Service – คลินิกเวชกรรม สวท

Basic Information

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UUID

Title(Required)

Name(Required)

Surname(Required)

Mobile Number(Required)

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Sex

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pmseu

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ID Card Number/Passport(Required)

Passport No.

DOB(Required)

Age(Required)

Personal Information

Weight(Required)

Height(Required)

Education(Required)

occupation(Required)

marital status(Required)

nationality(Required)

Address for pills delivery

region(Required)

current address(Required)

Subdistrict(Required)

District(Required)

province(Required)

zip code(Required)

Emergency Contact

contact name(Required)

Contact's last name(Required)

Mobile Number(Required)

Medical Information

Do you have a history of drug allergies?(Required)

a history of drug allergies(Required)

health history and regular medications(Required)

Gravidity (the number of times you are or have been pregnant regardless of outcome)(Required)

having children included(Required)

Youngest child age (years)(Required)

(month)(Required)

being a woman (person)(Required)

male (person)(Required)

method of childbirth(Required)

Have you had a miscarriage before?(Required)

ever

never

How many times have you had an abortion?(Required)

How is it a miscarriage?(Required)

What is the gestational age (weeks)?(Required)

More than 12 weeks (please specify gestational age)(Required)

Cause of pregnancy(Required)

Other reasons, please specify.(Required)

The reason for receiving abortion service(Required)

Other reasons, please specify.(Required)