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JIS Orthopedic Medical Questionnaire

Personal Information

Gender
Do you have a passport?:

Surgery Preferences

SMOKING/ALCOHOL/DRUGS

Recreational drug use
Do you smoke?
Do you drink alcohol?

MEDICAL HISTORY

CHECKLIST OF PREVIOUS ILLNESSES

Blood Pressure - High
Blood Pressure - Low
Heart Disorder (Angina, Congenital, Thrombosis, Fever, RH)
Diabetes
Kidney/Bladder Related
Liver Conditions, Jaundice
Ulcers (gastric, duodenal), Diarrhea, Hiatus Hernia
Asthma, TB, Bronchitis, Lung Disease
Varicose Veins, Thrombosis of Veins
Porphyria (Patient or members of family)
Epilepsy, any other muscular or neurological disease
Orthopedic problems
Excess bleeding (post-surgery or injury)
Tropical diseases Malaria etc
Any recent minor illnesses
If you feel there are any further details which may help us in providing you with they appropriate treatment/surgery information please specify below.
Recent copies of x-rays, scans, diagnosis reports, medical reports will help provide a more accurate estimate & medical opinion.
Do you have MRI Scans or X-Rays?
Do you have a treatment plan from your physician?
MRI/X-rays/Treatment Plan

Med Tourism Co LLC (www.medicaltourismco.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

The information I have provided is true and accurate and to the best of my knowledge.





*Please review our full disclaimers, Terms & Conditions and, Health Privacy & Confidentiality Statement. Individual results may vary. The statements on this website have not been evaluated by the FDA or any medical professional.

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