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National ID or Resident Certificate No.:
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Name: |
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Date of birth: |
Year
/
Month
/
Day
Please enter the Common Era
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Mobile / landline No. (fill in at least one)
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Mobile
landline: |
Permanent address: |
Postal code
Permanent address |
Emergency contact name: |
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Emergency contact mobile or landline No.: |
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Second-hand Smoke Exposure: |
No
Yes
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Smoking & Tobacco Use: |
Never smoker
Former smoker (quit smoking now)
Current smoker (Please fill out the following tobacco products you use)
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Smoke Cigarettes
Less than one pack a day
More than one pack a day
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Use Electronic Cigarettes (electronic powered vaping devices that produce aerosol by heating a liquid)
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Use Heated Tobacco Products (products that use an electronic device to heat a stick of tobacco)
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Alcohol Use: |
Non-drinker
Quit
Regular or frequent drinking alcohol
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Betel Nut Chewing: |
Non-chewer
Quit
Habitual betel nut chewer
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I agree that Taipei Veterans General Hospital can collect, process or use my medical records and related data for medical treatment, care services, or other specific purposes as follows.
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Iagree
disagree
Under the premise of medical treatment and care services, my medical records and related data collected by Taipei Veterans General Hospital can be provided to all branches (Taipei Veterans General Hospital Suao Branch, Taipei Veterans General Hospital Yuanshan Branch, Taipei Veterans General Hospital Taoyuan Branch, Taipei Veterans General Hospital Hsinchu Branch, Taipei Veterans General Hospital Fenglin Branch, Taipei Veterans General Hospital Yuli Branch, Taipei Veterans General Hospital Taitung Branch) for processing or use by hospital medical information system.(If consent is not given, the medical records and related data collected by Taipei Veterans General Hospital will be unable to provide to all branches for processing or use.) |
Iagree
disagree
According to article 5 to 9, 16, and 20 of the Personal Data Protection Act in Taiwan, Taipei Veterans General Hospital can notify me that the physician has asked for leave, substitute other physician for original one to consult, health education, health examination, patient associations, hospital news, outpatient schedule, new medical knowledge, teaching activities, care, and satisfaction related information by letters, e-mail, SMS, fax, or telephone.(If consent is not given, Taipei Veterans General Hospital will be unable to notify of the above-mentioned information.)
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I have read this document carefully, and have fully understood the content and related rights to provide the above personal data, and I still have the right to review my personal data, to request a copy of my personal data, to supplement or correct my personal data at any time.
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