Telemed – คลินิกเวชกรรม สวท

Basic Information

Title(Required)

name(Required)

Lastname(Required)

Mobile Number(Required)

Hidden

Sex

Hidden

pmseu

Hidden

Passport(Required)

Passport No.

DOB(Required)

Age(Required)

Basic information

Weight(Required)

Height(Required)

Education(Required)

occupation(Required)

marital status(Required)

nationality(Required)

address for drug delivery

region(Required)

current address(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)

How many times is it a pregnancy?(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 your 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 the termination of pregnancy is(Required)

Other reasons, please specify.(Required)

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