First / Given Name*
Last / Surname*
Telephone (with country code) * Gender*
-- Select Item -- Female Male
Date of Birth *
List substances used (alcohol, opiates, cannabis, benzodiazepines, methamphetamine, cocaine, etc.) *
Duration of use (how long, number of months or years for each)*
Amount per day for the substances*
Route taken to use the substances (drink, smoke, inject, swallow, etc.)*
Approximate date of last use of each substance*
Other information about substances we should know about (if applicable)*
For any of the health issues above, please provide more detail, and any medications used to treat these conditions.
Please describe other health issues not mentioned above, if any.
Please list any currently prescribed medication and dosages not mentioned above, if any.
Please indicate if you have any mobility issues. Note that Siam Rehab is not wheelchair-accessible, and there are stairs at our facility.
Previous Addiction Treatment
If you have attended any other rehab programmes in the past, please list, and indicate the dates of attendance, and the length of abstinence from substances after each rehab.
Arrival and Logistics
Preferred dates to begin rehab*
Allergies or special dietary needs*