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Questionnaire
Name* :
E-mail* :
Phone* :
Best time(s) to call (please specify region and/or time zone)
(Optional) :
Referred by   (Optional) :
 What sort of procedure(s) are you considering? (check all that apply)

Cosmetic/Plastic surgery
Gastroenterology Back/Spinal Cord/Neuro surgery
Dermatology and laser treatments Orthopedics/joint replacement/resurfacing
Eye care/opthalmology Dental care
Bariatric/Gastric bypass Gynecology and Obstetrics
Vascular surgery Stem cell transplant
Organ transplant Other
Have you discussed alternatives with a doctor?
Yes
No
Have you ever traveled outside North America?
Yes, often
Yes, a few times
Yes, once
No, never
Have you ever been diagnosed with any of the following
Heart disease Stroke Arthritis
Embolism High blood pressure High or low blood sugar
Respiratory problems Cancer HIV
Bleeding or clotting disorder Mental disorder Drug or food allergies
Spinal injury Hernia Reproductive disorders
Aneurism Obesity Vision disorders
Osteoporosis Neuromuscular disorders Dental problems
Please describe conditions not listed above
Your physician information
1. Name* :
  Address* :
  Phone* :
  Email* :
       
2. Name :
  Address :
  Phone :
  Email :

Are you under any medications? What do you take them for?
Medication Yes No If yes, What for
Describe any allergies to medications
Please list your previous hospitalizations and outpatient procedures.
Month Year Number of days Reason

Please list medical tests you have taken, give approximate month and year they were last done
1. Medical Test Month Year
2. Medical Test Month year
3. Medical Test Month year
Do you have any impairments or limitations? Please describe
Is there anything you think we should know in order to help us serve you better?

The information you provide assists our doctors to evaluate your medical condition for the desired treatment. Your privacy is guaranteed.
Your doctor’s information
1. Primary Physician
Name* :
Address* :
Phone* :
Fax :
 
2. Other specialist/physician
Name :
Address :
Phone :
Fax :

I certify that the above information is correct and complete. I have not withheld any information that is relevant for the doctor to judge on my medical history.
    * marks are mandatory
     
 
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