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.
 YesNo
Nighttime urination
Leaking urine
 YesNo
Difficulty hearing/ringing in ears
Hay fever/ allergies
 YesNo
Fevers/sweats/weakness
Unexplained weight loss/gain
 YesNo
Blood in stool
Nausea/vomiting/diarrhea
 YesNo
Breast lump/nipple discharge
 YesNo
Rash/new or change in mole
 YesNo
Chest pain/discomfort
Palpitations
 YesNo
Headaches
Memory loss
 YesNo
Anxiety/stress
Sleep problem/Depression
 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
 Answer
Status Family
 Answer
Lipid (cholesterol) Abnormal?; Sigmoidoscopy Abnormal?;Colonoscopy Abnormal? Mammogram Abnormal? Pap Smear Abnormal?;Men: PSA (prostate) Abnormal?
 Answer
Alcohol / Drugs / Tobacco : Use
 Answer
Do you exercise regularly?
 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