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.

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Personal Information

Name

First

Last

Layout

Date of Birth

Cell Phone

Nationality

Gender

Male
Female

Medical Information / History

What medical treatment(s) / procedure(s) are you interested in getting?

Are there any wobbly teeth? (for dental patients only)

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?

Are you diabetic?

Do you use aspirin or any of the blood thinners?

Any joint pain or arthritis?

Are you currently suffering any pain?

List any/all medication(s) you currently intake?

(including over the counter drugs, supplements, vitamins … etc.)?

Are you allergic to any medication?

Have you ever been diagnosed with a medical illness or disease?

Does your family have a history of any illnesses?

Have you ever been hospitalized?

Do you smoke tobacco?

Would you consider yourself an overall healthy person?

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

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Patient Medical History Evaluation Form

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