Bangkok Hospital Phuket
BPK
TH
Online Checkup Form
Choose your gender
Male
Female
Please indicate your age
Age 15-34
Age > 35
Age > 40
Age > 45
Age > 50
Please indicate your age
อายุ 15-34 ปี
อายุ > 35 ปี
อายุ > 40 ปี
อายุ > 45 ปี
Do you smoke often?
Yes
No
Did your next of kin ever have colorectal cancer?
Yes
No
Did your next of kin ever have heart disease and vascular disease?
Yes
No
Do you drink often?
Yes
No
Did your next of kin ever have diabetes?
Yes
No
Do you smoke often? Or did your next of kin ever have lung cancer?
Yes
No
In the past year, you had sexual intercourse. Did you not have cervical cancer examination?
Yes
No
In the past year, did you have breast cancer examination?
Yes
No
Did your next of kin ever have heart disease and vascular disease?
Yes
No
Did your next of kin ever have colorectal cancer?
Yes
No
Do any members of your family have had skin cancer?
Yes
No
Do any members of your family have a history of allergy?
Yes
No
Have you ever had any of the following symptoms?
Feeling weak and frail
Metabolism is ineffective; easily lose and gain weight
Change of skin texture: dry, wrinkled and decreasing muscle mass
Sleeping disorders: difficulty in maintaining sleep; snatch of sleep
Easily irritated; depressed; low sex drive
Yes
No
Would you like to know the levels of vitamins and antioxidants in your system to strengthen your body and make you stay lively all day?
Yes
No
Are you in these situations --- stay up late at night, experience high stress, and eat processed and instant foods often?
Yes
No
Do you feel exhausted and sleepy despite sleeping for 6-8 hours a night?
Yes
No
Do you exercise for more than 30 minutes and more than 3 times a week?
Yes
No
Do you work in an area where loud noises persist for hours?
Yes
No
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