I recall they also wanted a photo similar to the passport one. I DO remember bringing both the form and the photo for the 90 day reporting just to be pleasantly surprised that neither were required.
I'm flying back to the states where I have Medicare plus additional health insurance for cataract surgery in both eyes. In Thailand, out of pocket is 200,000 baht, same exact surgery out of pocket in US will be around 10,000 baht.