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, 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?	Excellent	Good	Fair	Poor

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

Cardiovascular

	Yes	No
Hypertension	Yes	No
Chest pain/discomfort	Yes	No
Palpitations	Yes	No
Angina Heart Attack	Yes	No

Endocrine

	Yes	No
Diabetes	Yes	No
Insulin	Yes	No
Hypoglycemia	Yes	No
Thyroid	Yes	No

Gastrointestinal

	Yes	No
Gastro-esophageal reflux	Yes	No
Ulcerative colitis	Yes	No
Hepatitis	Yes	No
Blood in stool	Yes	No
Nausea/vomiting/diarrhea	Yes	No

Neurological

	Yes	No
Headaches	Yes	No
Memory loss	Yes	No

Respiratory

	Yes	No
Cough/wheeze	Yes	No
Asthma	Yes	No
Bronchitis/Emphysema/COPD	Yes	No

Genitourinary

	Yes	No
Nighttime urination	Yes	No
Leaking urine	Yes	No

Constitutional

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

Psychiatric

	Yes	No
Anxiety/stress	Yes	No
Sleep problem/Depression	Yes	No

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

	Medication	Date	How many times per day
1	Medication	Date	How many times per day
2	Medication	Date	How many times per day

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

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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	Answer

HEALTH MAINTENANCE SCREENING TESTS

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

SOCIAL HISTORY

	Answer
Alcohol / Drugs / Tobacco : Use	Answer

EXERCISE:

	Answer
Do you exercise regularly?	Answer

WOMEN’S HEALTH HISTORY:

	Answer
# pregnancies;#deliveries;#abortions	Answer