Medical History Form

If you're ready to begin the process, this is a great place to start.There's no obligation. The information submitted by you is privileged and confidential, Bajanor Medical Center does not distribute or sell this information to 3rd parties,as it is used strictly for medical evaluation. Simply fill out the form below, and we'll contact you as soon as possible
Personal Information
 
 
Medical Information
 
 ExcellentGoodFairPoor
How would you rate your general health?
REVIEW OF SYMPTOMS: Please check any CURRENT symptoms you have.
Genitourinary 
 YesNo
Nighttime urination
Leaking urine

Ears/Nose/Throat/Mouth                                                    

 
 YesNo
Difficulty hearing/ringing in ears
Hay fever/ allergies
Constitutional 
 YesNo
Fevers/sweats/weakness
Unexplained weight loss/gain
Gastrointestinal 
 YesNo
Blood in stool
Nausea/vomiting/diarrhea
Breast 
 YesNo
Breast lump/nipple discharge
Skin 
 YesNo
Rash/new or change in mole
Cardiovascular 
 YesNo
Chest pain/discomfort
Palpitations
Neurological 
 YesNo
Headaches
Memory loss
Psychiatric 
 YesNo
Anxiety/stress
Sleep problem/Depression
Respiratory 
 YesNo
Cough/wheeze
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies,
birth control pills, herbs, etc.
 
 MedicationDateHow many times per day
1
2
0/255 characters

FAMILY HISTORY: Please indicate the current status of your immediate family members:

Please indicate family members (parent, sibling, grandparent, aunt or uncle)
with any of the following conditions:

 
 Answer
Status Family

HEALTH MAINTENANCE SCREENING TESTS                                 

 
 Answer
Lipid (cholesterol) Abnormal?; Sigmoidoscopy Abnormal?;Colonoscopy Abnormal? Mammogram Abnormal? Pap Smear Abnormal?;Men: PSA (prostate) Abnormal?

 SOCIAL HISTORY                         

 
 Answer
Alcohol / Drugs / Tobacco : Use

EXERCISE:

 
 Answer
Do you exercise regularly?
WOMEN’S HEALTH HISTORY:  
 Answer
# pregnancies;#deliveries;#abortions
 Indicates Response Required
Calle Ferrocarril No 10634 Col. Libertad Parte Baja C.P. 22300, Tijuana, B.C. México.
Toll Phone: 1-877-273-2104