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Personal Information

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Title

Gender

Last Name

First Name

Birthday

Birth of Place

Age

Home Address

City

Home Telephone

District

Office Telephone

Email

Mobile

HKID No. / Passport No.

Occupation

Referred By (Please Specify)

Nationality

Name of Referral

Emergency Contact

Emergency Contact Person

Relationship

Emergency Contact Number

Medical History

Rheumatic or scarlet fever

Asthma

Chest (e.g. Bronchitis, TB)

Jaundice or Hepatits

Gastro-Intestinal

High Blood Pressure

Heart Pacemaker

Heart Problems

Diabetes

Epilepsy

Prolonged Bleeding

A.I.D.S./H.I.V

Major Surgery / Hospitalization

Allergic to

Drugs/Medication Prescribed

Other Medical History

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