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KTGH 初診單 New Patient Registration Form
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1. 姓名Name: 中文姓名跟英文姓名（跟護照上相同的）都要寫！ 名（First name), 姓（Last name) *
2.性別 Gender *
3.生日:西元 年/月/日Date of Birth     Year/Month/Day *
4.健保卡NHI card Number或身分證字號
5.護照號碼(外國人填寫):Passport Number:
6.國籍:Nationality *
7.電話Telephone *
8.地址:Address *
9.緊急聯絡人Emergency Contact information  (人/關係/聯絡電話) (Emergency Contact/Relationship/Phone
10.職業Occupation
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11.過去病史Previous History
11.家族史Family History
13.健康行為史Health Behavior History
無No
有 Yes
已戒 Stopped
抽煙
喝酒
嚼檳榔
14.旅遊史Travel History (無 No/有 三個月內曾去哪些國家Yes, countries visited in the past 3 months)
15.電子信箱email
16.就醫原因 What is your request?
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