Healing Starts Here
Home
About us
Our Policies
Treatments
Cardiovascular Surgery
Aortic Vascular Surgery
Arterial Obstruction
Carotid Artery Surgery
Coronary Bypass Surgery
Heart Valve Surgery
Peripheral Artery Surgery
Varicose Veins Treatment
Neurology Diseases
Brain Vascular Diseases
Deep Brain Stimulation
Dementia
Demyelinating Diseases
Epilepsy
Headache
Movement Disorder
Muscle Diseases
Sleep Apnea
Plastic and Cosmetic Surgeries
Arm Lift
Body Contouring
Body Lifts
Breast Augmentation
Breast Lift
Breast Reduction
Brow Lift Surgery
Buttock Augmentation
Dermal Filler
Face Lift Surgery
Labiaplasty
Laser Hair Removal
Liposuction
Male Breast Reduction
Mommy Make Over
Nose Surgery
Skin Cancer Removal
Scar Revision
Spider Vein Treatment
Thigh Lift
Tummy Tuck
Orthopedic Treatments / Surgeries
Arthroscopic Surgery
Athletic Rehabilitation
Foot and Ankle Surgery
Hand and Wrist Surgery
Hip Replacement
Knee Surgery
Knee Replacement Surgery
Shoulder Surgery
Spine Surgery
Sports Medicine
Other Treatments / Surgeries
Bariatric Surgery
Dental Implant & Cosmetics
Hair Transplant
Infertility Treatment
Parathyroid Transplant
Our Services
Testimonials
Blog
Contact us
Client Portal
Meetings and Events Management
Patient Medical History Evaluation Form
Patient Medical History Evaluation Form
Please be advised that the Patient Medical History Evaluation form will be shared with 3 hospitals for evaluation by 3 physicians and to provide estimated treatment cost. Please be accurate with the information you are about to provide. Estimated Completion time: 10-15 minutes.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Personal Information
Name
*
First
Last
Layout
Date of Birth
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Cell Phone
*
Email
*
Nationality
*
Afghan
Albanian
Algerian
American
Andorran
Angolan
Anguillan
Argentine
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Botswanan
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinan
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Cayman Islander
Central African
Chadian
Chilean
Chinese
Citizen of Antigua and Barbuda
Citizen of Bosnia and Herzegovina
Citizen of Guinea-Bissau
Citizen of Kiribati
Citizen of Seychelles
Citizen of the Dominican Republic
Citizen of Vanuatu
Comoran
Congolese (Congo)
Congolese (DRC)
Cook Islander
Costa Rican
Croatian
Cuban
Cymraes
Cymro
Cypriot
Czech
Danish
Djiboutian
Dominican
Dutch
East Timorese
Ecuadorean
Egyptian
Emirati
English
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Faroese
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltarian
Greek
Greenlandic
Grenadian
Guamanian
Guatemalan
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakh
Kenyan
Kittitian
Kosovan
Kuwaiti
Kyrgyz
Lao
Lativian
Lebanese
Liberian
Libyan
Liechtenstein citizen
Lithuanian
Luxembourger
Macanese
Macedonian
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Marshallese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monegasque
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
Nicaraguan
Nigerian
Nigerien
Niuean
North Korean
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Palestinian
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Pitcairn Islander
Polish
Portuguese
Prydeinig
Puerto Rican
Qatari
Romanian
Russian
Rwandan
Salvadorean
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Scottish
Senegalese
Serbian
Sierra Leonean
Singaporean
Slovak
Slovenian
Solomon Islander
Somali
South African
South Korean
South Sudanese
Spanish
Sri Lankan
St Helenian
St Lucian
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian
Tristanian
Tunisian
Turkish
Turkman
Turks and Caicos Islander
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vatican citizen
Venezuelan
Vietnamese
Vincentian
Wallisian
Welsh
Yemeni
Zambian
Zimbabwean
Gender
*
Male
Female
Medical Information / History
Layout
Weight
*
Height
*
Metric
*
Please select
lbs.
Kg.
Metric
*
Please select
Feet
Centimeter
Inches
What medical treatment(s) / procedure(s) are you interested in getting?
*
Are there any wobbly teeth? (for dental patients only)
*
Yes
Yes
No
Why do you want to get this medical treatment / procedure done?
When are you planning to start the treatment / procedure?
Have you had any previous surgeries?
*
Yes
Yes
No
If YES, Please explain
Are you diabetic?
*
Yes
Yes
No
Do you use aspirin or any of the blood thinners?
*
Yes
Yes
No
Any joint pain or arthritis?
*
Yes
Yes
No
Are you currently suffering any pain?
*
Yes
Yes
No
If YES, Please explain
List any/all medication(s) you currently intake?
(including over the counter drugs, supplements, vitamins … etc.)?
Are you allergic to any medication?
*
Yes
Yes
No
If YES, Please explain
Have you ever been diagnosed with a medical illness or disease?
*
Yes
Yes
No
If YES, Please explain
Does your family have a history of any illnesses?
*
Yes
Yes
No
If YES, Please explain
Have you ever been hospitalized?
*
Yes
Yes
No
If YES, Please explain
Do you smoke tobacco?
*
Yes
Yes
No
Would you consider yourself an overall healthy person?
*
Yes
Yes
No
If NO, Why?
List all medical conditions (if any) - Leave blank if NON
List any other facts about your health or yourself in general which you feel the physician should be aware of before you undergo any type of medical procedure.
Securely upload any medical reports or x-ray / MRI images that you would like to share with the concerned physician (if any). For dental and plastic surgery patients, please upload front and side photos of the areas need treatment or require any medical procedure.
Click or drag files to this area to upload.
You can upload up to 10 files.
Allowed file formats: .png, .gif, .jpg, .doc, .xls, .ppt, .pdf - X-ray and MRI images preferably in PDF file.
Declaration:
*
I hereby declare that the information furnished above is true, complete and correct to the best of my knowledge and belief. I understand that in the event of my information being found false or incorrect at any stage, I shall be liable for providing false medical information related to my health.
Name
*
Submit
Share this:
Facebook
X
Email
LinkedIn
WhatsApp
Like this:
Like
Loading...
1
Talk to us!
%d