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
How would you rate your general health?
REVIEW OF SYMPTOMS: Please check any CURRENT symptoms you have.
Nighttime urination
Leaking urine
Difficulty hearing/ringing in ears
Hay fever/ allergies
Unexplained weight loss/gain
Blood in stool
Breast lump/nipple discharge
Rash/new or change in mole
Chest pain/discomfort
Memory loss
Sleep problem/Depression
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies,
birth control pills, herbs, etc.
 MedicationDateHow many times per day
0/255 characters
Status Family
Lipid (cholesterol) Abnormal?; Sigmoidoscopy Abnormal?;Colonoscopy Abnormal? Mammogram Abnormal? Pap Smear Abnormal?;Men: PSA (prostate) Abnormal?
Alcohol / Drugs / Tobacco : Use
Do you exercise regularly?
# 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