Bajanor 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

Height

Weight: (lb)

Waist:(in)

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

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

Cardiovascular

	Yes	No
Chest pain/discomfort
Palpitations

Neurological

	Yes	No
Headaches
Memory loss

Blood/Lymphatic

	Yes	No
Unexplained lumps
Easy bruising/bleeding

Psychiatric

Respiratory

	Yes	No
Cough/wheeze

Skin

	Yes	No
Rash/new or change in mole

	Yes	No
In the past month, have you had little interest or pleasure in doing things, or felt low, depressed or hopeless

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

	Medication	Date	How many times per day
1
2
3
4
5

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

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
Cancer, specify type
Heart Attack
Depression/Suicide
Alcoholism
Diabetes
High Cholesterol
High Blood Pressure
Stroke
Other

HEALTH MAINTENANCE SCREENING TESTS SOCIAL HISTORY

Tobacco Use

Alcohol Use

Drug Use

	Yes	No
Do you use any recreational drugs?
Have you ever used needles to inject drugs?

Other Concerns

	Yes	No
CAFFEINE Intake
Coffee/tea/soda
WEIGHT: Are you satisfied with your weight?
DIET: How do you rate your diet? :Good
DIET: How do you rate your diet? :Fair
DIET: How do you rate your diet? :Poor
Calcium supplements?

EXERCISE:

	Answer
Do you exercise regularly?
What kind of exercise?
How long (minutes
How often?
If you do not exercise, why?

WOMEN’S HEALTH HISTORY:

	Answer
# pregnancies
# deliveries
# abortions
# miscarriages
1st day of most recent period

Indicates Response Required

	Yes	No
Nighttime urination
Leaking urine
Unusual vaginal bleeding
Discharge: penis or vagina

	Yes	No
Lipid (cholesterol) Abnormal?
Sigmoidoscopy Abnormal?
Colonoscopy Abnormal?
Mammogram Abnormal?
Pap Smear Abnormal?
Men: PSA (prostate) Abnormal?

	Yes	No
Cigarettes
If Current Smoker( more 1 packs/day )
Other Tobacco(Pipe, Cigar, Snuff, Chew)
Are you interested in quitting?

	Yes	No
Do you drink alcohol?
Daily
Weekend
Is your alcohol use a concern for you or others?

	Yes	No
Anxiety/stress
Sleep problem
Depression