Medical History Form

Most of this is optional. Field with red asterisk is required. * Complete info is best

Personal Information

First Name / Given Name * (like in passport)

Surname / Family Name * (like in passport)

Date of Birth * (month, day, year)

Gender *

Nationality

Physical Details

Weight (specify kg or lbs)

Height (specify cm or inches)

BMI

Diagnosis * (specify your health problem)

Have you had previous surgeries? (list procedures and date performed in chronological order)

Procedures Required *

Planned Surgery Date (month, date, year — 1st, 2nd, 3rd choice)

Do you have any specific questions for the doctor?

Are you aware of the possible risks involved in getting the procedure you want?

Yes No

Are you aware of the possible complications that could occur from the treatment you want?

Yes No

Your Email Address *

Phone (include country code)

Preferred Language

Current Address

We encourage you to provide emergency contact info

Do you have Hepatitis B, Hepatitis C or are you HIV+? (if yes, explain)

Yes No

Please specify

Do you have any allergies? (explain in detail)

Yes No

Anti-spam: What is 7 + 4? *