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你的旅程
1. 试管婴儿前期检查
如何在体外受精前准备
Pregnable 培孕宝
2. 体外受精过程
试管婴儿流程指南
试管部门医生&实验室
试管婴儿部门费用
3. 前往泰国
在線預訂
BNH服务
BOOCS健康疗法
儿科
保育室
網上商店
泰国 BNH 医院
联系我们
ผู้ป่วยที่แยกตัวที่บ้าน - ชาวต่างชาติ
Report for Covid-19 patient
Fullname
*
Passport
*
Sex
*
male
female
Age
*
Nationality
*
Type
*
having respiratory condition
close contact with confirmed Covid-19 case
Active case finding
Sentinel surveilance
Other
Other
Occupation
*
Phone
*
Email
*
Work place / School
*
Address in Thailand
*
Residential style
*
detached house
townhouse
apartment
shared rooms with many people, such as construction camps, hospital wards
Other
Other
Date of illness
*
Admission date
*
COVID-19 diagnosis date
*
Sign and symptoms (Today)
*
no sign and symptoms
having symptoms but no respiratory condition
having respiratory condition
Medical condition
*
Are you pregnant?
*
No
Yes ... week
Yes ... week
Covid test date
*
Type of Covid-test
*
RT-PCR
ATK
Type of swab
*
Long swab
Short swab
Inspection site
*
Inspection site
*
Have you ever been vaccinated against COVID-19?
*
never received
received 1 time
received 2 times
Do you have evidence of vaccination?
*
have
haven't
1st received date
*
Name of vaccine received 1st time
*
Injection site 1st time
*
2nd received date
*
Name of vaccine received 2nd time
*
Injection site 2nd time
*
What province are you currently in?
*
*** Please read carefully*** History during 14 days before illness
*
Closed contact with Influenza patient or Pneumonia patient
Closed contact with confirmed corona virus 2019 patients or confirmed case's secretion
Work with tourist , crowded areas or contact with many people
Stayed/visited in communities or areas with many people such as ( department store, hospital, public transport, Gambling den, Karaoke room, Pub, Boxing stadium) where found case COVID19 confirmed within 1 month.
Other
Other
Names of close patients who have been in contact with COVID-19
*
Specify where you go
*
Number of close contacts without protective equipment such as masks (high risk)
*
Number of close contacts with whom you have worn protective equipment such as masks (low risk)
*
Consent Form for Home Isolation
I am...
*
a patient
patient guardian
State why the patient is not able to give consent personally (or to sign this form)
*
Minor-any unmarried male or female whise age has not reached the age of consent (20 years old)
Physical / Mental disorder
Other
Other
Fullname
*
Age
*
Passport No.
*
Your fullname
*
Your age
*
Your passport number
*
Fullname's patient
*
Age's patient
*
Relationship
*
First day of illness
*
Where do you stay ?( Please specific in detail)
*
Phone number
*
Close contact person 1st
*
Phone number of close contact person 1st
*
Close contact person 2nd (if you have)
Phone number of close contact person 2nd (if you have)
Do you have pulse oximeter and temperature monitor at home?
*
Don't have both (1,100THB)
Don't have pulse oximeter (1,000THB)
Don't have temperature monitor (100THB)
Signature
*
Clear
Submit
你的旅程
1. 试管婴儿前期检查
如何在体外受精前准备
Pregnable 培孕宝
2. 体外受精过程
试管婴儿流程指南
试管部门医生&实验室
试管婴儿部门费用
3. 前往泰国
在線預訂
BNH服务
BOOCS健康疗法
儿科
保育室
網上商店
泰国 BNH 医院
联系我们
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