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

Name

Age

Gender

Street Address

City/State/Zip code

Phone Number

Email Address

Please email me updates

Height

Weight: (lb)

BMI

Medical Information

Procedure(s) requested?

When (month/date) are you interested in getting the procedures completed?

Please write a short description of why you are interested in traveling
internationally to get your medical procedures completed.

	Excellent	Good	Fair	Poor
How would you rate your general health?

REVIEW OF SYMPTOMS: Please check any CURRENT symptoms you have.

Genitourinary

	Yes	No
Nighttime urination
Leaking urine

Ears/Nose/Throat/Mouth

	Yes	No
Difficulty hearing/ringing in ears
Hay fever/ allergies

Constitutional

	Yes	No
Fevers/sweats/weakness
Unexplained weight loss/gain

Gastrointestinal

	Yes	No
Blood in stool
Nausea/vomiting/diarrhea

Breast

	Yes	No
Breast lump/nipple discharge

Skin

	Yes	No
Rash/new or change in mole

Cardiovascular

	Yes	No
Chest pain/discomfort
Palpitations

Neurological

	Yes	No
Headaches
Memory loss

Psychiatric

	Yes	No
Anxiety/stress
Sleep problem/Depression

Respiratory

	Yes	No
Cough/wheeze

MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies,
birth control pills, herbs, etc.

	Medication	Date	How many times per day
1
2

SURGICAL HISTORY: Please list all prior operations (with dates).

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