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Liposuction Center of Thailand Online History Form
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First Name
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Last Name (Family Name)
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Date of Birth (Please provide CORRECT YEAR of birth)
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Year
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Gender
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Male
Female
Height ( Please Specify CM or Feet & Inches)
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Weight ( Please Specify Pounds or Kilos )
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Where Do You Live?
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Street Address
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone
*
Email
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Emergency Contact Name and Phone Number (family,caregiver or close friend)
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What Treatment Are You Interested In?
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COSMETIC SURGERY
Stem Cell Breast Augmentation (CAL Breast Augmentation)
Breast Augmentation
Breast Lift (Mastopexy)
Breast Reduction (Reduction Mammaplasty/Mastectomy))
Buttocks Augmentation
Buttocks Lift
Chemical Peel (Skin Refinishing)
Chin Surgery (Mentoplasty)
Dermabrasion (Skin Refinishing)
Ear Surgery (Pinnaplasty)
Bat Ear Surgery (Otoplasty)
Eyelids (Blepharoplasty)
Face / Neck Lift (Rhytidectomy)
Facial Implants (Chin, Cheek & Jaw Surgery)
Facial Line Filling
Forehead / Brow Lift
Injectable Fillers (Improving Skin Texture)
Liposuction (Lipoplasty)
Male Breast Reduction (Gynecomastia)
Nose Surgery (Rhinoplasty)
Thigh Lift
Upper Arm Lift (Brachioplasty)
Tummy Tuck (Abdominoplasty)
Varicose Vein Removal
Spider Veins (Sclerotherapy)
Varicose Vein Laser Removal
STEM CELL TREATMENTS
Stem Cell Treatment for Autism
Stem Cell Treatment for Diabetes
Stem Cell Treatment for Heart Disease
Stem Cell Treatment for Anti-Aging
Stem Cell Treatment for Spinal Injuries
Stem Cell Treatment for Erectile Dysfunction (ED)
Other Stem Cell Treatment (Please Specify Below)
SRS GENDER REASSIGNMENT
MTF
FTM
DENTAL TREATMENT
Dental Bonding
Dental Bridges
Dental Crowns
Dental Fillings
Dental Implants
Dentures
Root Canals
Teeth Whitening
Tooth Contouring and Reshaping
Tooth Veneers
ORTHOPEDIC JOINT SURGERY
ACL Repair
Ankle Fusion Operation - Arthodesis
Carpal Tunnel Decompression
Discectomy - Slipped Disc
Hip Replacement
Hip Resurfacing
Knee Arthroscopy
Knee Replacement
Shoulder Arthroscopy
Shoulder Tendon Repair - Rotator Cuff
Spinal Fusion
Spinal Stenosis Operation
Spine - Total Disc Replacement (TDR)
Mastectomy
Mastectomy - Male Subcutaneuos
Angioplasty (Balloon & Stent)
Coronary Artery Bypass Graft (CABG)
Radio Frequency Ablation
Valve Replacement Surgery
DIAGNOSTICS AND CHECKUPS
24 hour holter (EKG) monitoring
Carotid Angiography
CT Scan
Cardiac Catheterization (Coronary Angiogram)
Echocardiography
Electrocardiogram (EKG)
Electrophysiology Testing (Arrythmia)
Exercise Echocardigraphy
Exercise Stress Testing
MRI
Myocardial Biopsy
Ultrasound
X-Ray
EYES EARS NOSE THROAT
Nasal Polyp Removal
Septoplasty
Tonsillectomy (Adult)
Turbinates of Nose - Excision
Cataract Surgery
LASIK Laser Refraction
Macular Degeneration
Retinal Surgery / Vitrectomy
INFERTILITY TREATMENTS
PGD Gender Selection
Assisted Hatching (AH)
In Vitro Fertilization Treatment (IVF)
Intracytoplasmatic Sperm Injection (ICSI)
Intrauterine Insemination (IUI)
OTHER
Cholecystectomy - Gall Bladder Removal
Hernia Repair - Epigastric
Hernia Repair - Femoral
Hernia Repair - Inguinal
Thyroidectomy
Prostatectomy
Vasectomy
Vasectomy Reversal
Colectomy - Total - and Ileostomy
Colon Polyp Removal
Colonoscopy
WEIGHTLOSS
Gastrectomy - Vertical
Gastric Banding (Lap Band)
Gastric Bypass (RNY)
Gastroscopy
Hemi-Colectomy - Left
Hemi-Colectomy - Right
Sigmoid-Colectomy
OTHER PLEASE SPECIFY BELOW
Please Describe Your Expectation of outcome
*
FOR WOMEN ONLY (CHECK ALL THAT APPLY)
I take birth control pills/hormone replacement/wear a patch.
I am pregnant now
I am planing more pregnancies
I am still breastfeeding/ My breasts still have milk at this time
FOR WOMEN ONLY - When Did You Deliver Your Last Baby?
DD
MM
YYYY
FOR WOMEN ONLY -When did you last breast feed?
DD
MM
YYYY
For Women having Breast Surgery of Tummy Tuck : How old is your youngest child? (Month&Year)
Have you had any surgery or been hospitalized in the past 2 years?
Yes
No
If Yes, please elaborate when and cause(s).
Do you currently or have you suffered from any of the followings Or Select "None of The Above"
*
Allergies to food/ vaccination/ drugs/ hay fever.
Nervous Breakdown / Depression
Lung Diseases
Cancer
Tumor
Asthma
Gastrointestinal problems
Epilepsy
Liver Problems
Hepatitis A
Hepatitis B
Hepatitis C
Renal Failure
Musculoskeletal problems
Osteoporosis
Osteoarthritis
Rheumatoid Arthritis
Blood Disorders
Thrombosis
Dibetes type 1
Diabetes type 2
Thyroid disorder - overactive
Thyroid disorder - underactive
Menopause
HIV/AIDS
NONE OF THE ABOVE.
Choose ALL that apply.
If Yes to any of the above, please elaborate.
Do you have artificial implants or any metal objects in your body? If yes, please specify.
If None Type "None" or "N/A"
Do you have difficulty with healing or scarring?
Yes
No
If YES Please Provide More Information
Do you have any symptoms for Sensory Loss in any of your body parts?
Upper limbs
Lower limbs
Pelvis Region
Face below eyes
Loss of smell
None of the above
Choose ALL that apply
Please list all supplements and medications you are currently taking:
*
Pls mention dosage/strength - date started & date stopped - If None Type "None" or "N/A"
Have you ever taken a MAO inhibilator, such as Naradil, Marplan or Parnate? If yes, when was your last dose?
*
If None Type "None" or "N/A"
Are you Allergic to ANY medications? If yes, please elaborate
If None Type "None" or "N/A"
Do You... (Choose all that apply)
*
Smoke
Drink - Occasionally
Drink- Everyday
None of the above
Estimated date you would like the Treatment?
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Month
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Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1930
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1922
1921
1920
Comments or Other Requests. Please state your question(s) to surgeon if any.
How Did You Hear About The Liposuction Center of Thailand?
Google Search
Bing or Yahoo Search
Friend or Personal Referral
TV Story or Other
Other - More Information on how your found us
If You Need To Send More Than 4 Pictures, Please Email Them To:
******IMAGE SIZE NOTE*****
Please try to attach images less than 1MB each. Larger images may cause upload/form failure. For Larger/Multiple Large images please use email instead
Please Attach Full FRONT View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach RIGHT Side View Photo of the Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach LEFT Side View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
(.jpg,.gif,.png,.pdf,.doc format ONLY)
Please Attach BACK View Photo of Concerned Area Here
Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.
If you have more pics in case of several areas concerned or are having problems uploading, please email them to Help@liposuctionthailand.org
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