| Your medical records |
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Name |
Name shown in your passport |
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| DOB (dd/mm/yyyy) |
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| Gender |
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| Address(in full) |
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| Email |
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| Phone number |
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| Emergency contact |
Relationship |
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| Name |
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| contact number |
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| Email |
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| Medical Records |
Height/Weight |
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| Diagnosis / Suspected diagnosis from your doctor |
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| Symptoms |
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| Medical examinations/screenings you went through |
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| Treatments you have received so far |
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| What is your doctor’s treatment plan? |
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| History of illness |
(Hepatitis, tuberculosis, diabetes, hypertension and etc.) |
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| Allergies |
(Food, Medications and etc.) |
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| Have you been through any surgeries in the past? |
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| Do you take any regular medications? What are they? |
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| Is there any medication that you currently stopped? |
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| Upload Medical Records |
Add medical records |
No files selected
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| Add X-rays, radiology results |
No files selected
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| Add laboratory results |
No files selected
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