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Stem Cells Medical Questionnaire
Stem Cells Medical Questionnaire
Personal Information
We do not share this information. Any other disclaimer.
First Name
*
Last Name
*
Gender
*
Male
Female
Other
Email
*
Date of Birth
Age
*
Do you have a passport?:
*
Yes
No
-Select Height (feet)-
4 ft.
5 ft.
6 ft.
7 ft.
-Select Height (inches)-
0 in.
1 in.
2 in.
3 in.
4 in.
5 in.
6 in.
7 in.
8 in.
9 in.
10 in.
11 in.
Current Weight
LBS
KG
City
*
Postal / Zip Code
Emergency Contact
First Name
*
Last Name
*
Relationship
*
Email
*
Telephone No (Home)
*
Telephone No (Business)
*
Surgery Preferences
Desired Medical Procedure
*
.
Desired Destination
*
.
Proposed Surgical Date
PRIMARY HEALTHCARE
Please name your medical condition or disease:
The reason why I need this examination is:
When were you diagnosed with this medical condition?
Please list all medication you are currently taking:
Please list all supplements you are currently taking:
Is your general health good?
*
Yes
No
Has there been a change in your health within the last year?
*
Yes
No
Have you gone to the hospital or emergency room or had a serious illness the last three years? *
*
Yes
No
Are you being treated by a physician now?
*
Yes
No
Are you in pain now?
*
Yes
No
Have you done any spinal cord surgery?
*
Yes
No
PERSONAL MEDICAL HISTORY
Please select which of the following have you experienced:
Chest pain (angina)
Night sweats
Blood stools
Ringing in ears
Bruise easily
Excessive thirst
Fainting spells
Persistent cough
Diarrhea or constipation
Headaches
Vomiting
Difficulty swallowing
Recent significant weight loss
Bleeding problem
Frequent urination
Dizziness
Jaundice
Swollen ankles
Fever
Blood in urine
Difficulty urinating
Blurred vision
Dry mouth
Joint pain
If you have experienced any other (explain)
Have you suffered from any of the following?
Diabetes
*
Yes
No
Diabetes while pregnant
*
Yes
No
Asthma
*
Yes
No
Respiratory/Breathing problems
*
Yes
No
Arthritis or joint pain
*
Yes
No
Kidney or urinary disorder
*
Yes
No
Neurological disorder
*
Yes
No
Psychological/nervous disorder
*
Yes
No
Gallstones
*
Yes
No
Thrombosis or clotting disorder
*
Yes
No
Gastric or duodenal ulcer
*
Yes
No
Hepatitis or liver disease
*
Yes
No
High blood pressure
*
Yes
No
Heart disease
*
Yes
No
High cholesterol
*
Yes
No
Anemia or bleeding disorder
*
Yes
No
Varicose veins or leg swelling
*
Yes
No
Eczema or skin condition
*
Yes
No
Hayfever or Rhinitis
*
Yes
No
Back pain
*
Yes
No
Any other
List all medications you currently take including dosage
SMOKING/ALCOHOL/DRUGS
We do not share this information. Any other disclaimer.
Recreational Drug Use?
*
Yes
No
Smoking Habit?
*
Often
Sometimes
Never
Any allergies:
*
Yes
No
Alcohol Consumption?
*
Often
Sometimes
Never
WOMEN ONLY
Are you or could you be pregnant?
*
Yes
No
Are you nursing?
*
Yes
No
Are you taking birth controlling pills?
*
Yes
No
CHECKLIST OF PREVIOUS ILLNESSES
Do you have any other diseases or medical condition NOT listed on this form?
*
Yes
No
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.
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I have read the above statement, Terms & Conditions & Health Privacy & Confidentiality Statement on the Medical Tourism Corporation Website.
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