1.*Name :

2.*Gender :

3.*Birthday :

4.*Nationality :

5.*Language :

6.*E-mail :

7.*Contact number :
(09XX-XXXXXX)

8.The hospital is currently being treated 
(Please fill in the current hospital, if not please write "none")

9.*Has the patient previously been treated at Taipei Veterans General Hospital?
(Please fill in "Yes," "No," or "Not sure.")

10.*Current medical history and treatment status
(Please describe your condition in detail, check the findings, the name of the drug, and the treatment)

11.Disease-related issues and supplements
(Please describe it in detail for follow-up consultation)

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