True Thai Medication Form
These questions are asked for your own safety. The information given will be treated as private and confidential, and will not be revealed to any third party without your prior authorisation in writing.
Name - Surname
Do you suffer from any of the following Medical Conditions?
Please tick if yes.
Are pregnant or breast feeding?
Are you trying to get pregnant?
Are you taking any medication?
Have you had any surgery in the past 9 months?
Is there any history of family illness?
Is your sleep disturbed?
Do you smoke?
Do you exercise regularly?
Please state the particular area if needed to be treated.
I confirm (to the best of my knowledge) that the answers I have given are correct, and that I have not withheld any information that may relevant to my treatment. I confirm that Nongnuch Thongkhong (True Thai Edinburgh) will not be held responsible for any adverse reaction caused by withholding information.
Signature & Date
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This form was created inside of True Thai Therapy.