Gender	Male       Female
First Name	*
Last Name	*
E-mail address	*
Telephone number	*
	I am a regular customer of Samitivej Hospital

     

Personal Information • Date of birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910
Do you have cancer? • Colon Cancer No Yes    No Yes    • Prostate Cancer No Yes      - • Skin Cancer No Yes    No Yes    • Stomach Cancer No Yes    No Yes    • Cervix Cancer   - No Yes    • Breast Cancer   - No Yes    • Other Cancer
Daily routines or habits • Are you a smoker? No Yes    No Yes    • How many cigarettes do you smoke per day?   Amount/Day   Amount/Day • How long have you been smoking?   Years   Years • Are you a drinker? No Occasionally Regularly    No Occasionally Regularly    • If drinking regularly, how often per week?   days/week   days/week
Do you have any of these conditions in your family medical history? • Heart Attack No Yes    No Yes    • Diabetes No Yes    No Yes    • Hypertension No Yes    No Yes    • Lung Cancer No Yes    No Yes    • Liver Cancer No Yes    No Yes    • Colon Cancer No Yes    No Yes    • Breast Cancer   - No Yes    • Cervix Cancer   - No Yes
Women Check up • Cervical cancer screening   - (Thin prep pap smear)    • Breast cancer sceening   - (Mammogram is recommended for female over 40 ys. Ultrasound breast is recommended for female under 40 ys.)

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