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TMV Online Medical History Form

TMV Online Medical History Form

Please fill out this short Medical History form and Attach all pics. We will get in touch with you shortly.

Name*

First
Last
Date of Birth*
Gender*
- Male
- Female
Height ( Please Specify cm or feet & inches)
Weight ( Please Specify Pounds or Kilos )
Address*

Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code

Country
Phone*
Email*
Contact Name in case of Emergency (caregiver,close friend or relative)
Contact Phone in case of Emergency (caregiver,close friend or relative)*
What Treatment are You interested In?
Comments or Other Requests
FOR WOMEN ONLY ( CHECK ALL THAT APPLY )
- Do you take birth control pills,hormone replacement or wear a patch?
- Are you pregnant now?
- Are you planning any more pregnancies?
FOR WOMEN ONLY – When Did You Deliver Your Last Baby?

DD

MM

YYYY
FOR WOMEN ONLY -When did you last breast feed?

MM

DD

YYYY
Do you currently have or have you ever suffered from:
- ANY Surgeries in the past 2 years
- Allergies: food, vaccination, drugs, hay fever
- Heart problems
- High blood pressure
- Asthma
- Lung disease
- Epilepsy
- Psychiatric problems – nervousness, depression
- Gastrointestinal problems
- Liver problems
- Hepatitis type: A
- Hepatitis type: B
- Hepatitis type: C
- Renal problems
- Kidney infections
- Musculoskeletal problems
- Osteoporosis
- Osteoarthritis
- Rheumatoid arthritis
- Blood disorder
- Thrombosis
- Diabetes type 1
- Diabetes type 2
- Thyroid disorder (pick one below)
- Overactive
- Under active
- Menopause
- HIV/AIDS
- Cancer
(CHECK ALL THAT APPLY)
If You Selected YES on anything above please elaborate
Are you currently on any of the following?
- Chemotherapy
- Anticoagulants
- AntiBiotics
- Sterioids
Do you have any Symptoms for Sensory Loss In Your Upper Limbs?*
- Yes
- No
Do you have any Symptoms for Sensory Loss In Your Lower Limbs?*
- Yes
- No
Do you have any Symptoms for Sensory Loss In Your Pelvis Region?*
- Yes
- No
Do you have any Symptoms for Sensory Loss In Your Face below Eyes?*
- Yes
- No
Do you have any Symptoms or Showing Any Signs of Loss of Smell?*
- Yes
- No
Vision – Do you have any Visual Field Loss -Central or Peripheral ?*
- Yes
- No
Are you currently taking ANY medications?*
- Yes
- No
If YES please provide the Names – Dosage/Strength – Date Started -Date Stopped

Dosage/Strength – Date Started -Date Stopped
Are you Allergic to ANY medications? Please Provide Below
Do You Smoke?*
- Yes
- No
Do You Drink?
- No
- Occasionally
- Every Day
Estimated date you would like the Treatment?
How Did You Hear About Thai Medical Vacation?
- Internet Search
- TV / Radio Ad
- Personal Referral
- Other
Other – More Information on how your found us
Please Attach Any Pictures/Files Here

(.jpg,.gif,.png,.pdf,.doc format ONLY)
File

(.jpg,.gif,.png,.pdf,.doc format ONLY)
File

(.jpg,.gif,.png,.pdf,.doc format ONLY)
File

If you have more pics or are having problems uploading please email them to help@ thaimedicalvacation.com
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Name*
Email*
Phone
What Country Do you Live in?
What Treatments Are You Interested In?*
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What Country Do you Live in?
What Treatments Are You Interested In?*
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