Medical Travel Company

Health Questionnaire

PROVIDING BASIC HEALTH INFORMATION CAN IMPROVE YOUR CARE

All patients are requested to complete a health questionnaire. It helps us to understand you better prior to your doctor consultation and designed to create a more effective medical assessment.

Important information about you leads to better results, quality, safety, and satisfaction.

All information given on this form is kept strictly confidential and revealed to no one without your permission.

Birth date:
Height: cm
Weight: kgs
Gender
Chief Complaint
Are you a smoker?
Alcohol?
Infectious Diseases?
Birth control?
Blood pressure?
Heart problems?
History of DVT (Deep Vein Thrombosis / Blood Clots)?
Diabetes?
Difficulties with General Anesthesia?
Difficulties with Physical Activities?
Do you have any known allergies to medications, latex, or surgical tape?
Medications

What medications are you currently taking? Include over-the-counter. If any, please write Name / Dosage / Frequency.

Prior Surgery

If any, please write Name / Date.

Notes

Do you have any questions?

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