Smart Health Assessment | Bangkok Hospital Pattaya

Skin Cancer Risk Assessment

แบบประเมินความเสี่ยงมะเร็งผิวหนัง

Bangkok Hospital Pattaya

*First name

*Last name

Hospital Number [HN] (if known)

*Gender

Male Female

*Date of birth

*Height (cm.)

*Weight (kg.)

*Contact number

E-mail

Skin Cancer Risk Assessment

This is a multiple answer question so you may choose more than one answer if you’d like

	Family history of skin cancer
	Over 40 years old with a history of sunbathing or engaging in outdoor activities under the sun.
	The skin has developed a rapidly growing lump within 1-3 months.
	A mole has changed in shape and color from its original state.
	There is a lump on the skin that has developed a sore or bleeds easily.
	There is a black or brown lesion with unclear borders and the development of a sore.
	A chronic rash has changed into a raised lump.

I agree the data collection, data manipulation and disclosure. Including your health information for health assessment system only.
The hospital has announced a personal information protection policy.

I agree to be contacted by the hospital for information and related services.