Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Birth
City/State or Town/Country if not in the US
Gender
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Divorced
Widowed
Long Term Partnership
Blood type
A
B
AB
O
Rh+
Rh-
Unknown
Are you experiencing any of the following symptoms?
cough >3 weeks
unexplained weight loss
coughing up blood
drenching night sweats
Have you had known contact with someone known to have TB disease?
Yes
No
Did you receive your childhood vaccinations?
Yes
No
Unknown
Please Answer the Following Questions
Rows
Yes
No
Unknown
HPV (Gardasil)
Tetanus (TdaP)
Hepatitis A
Hepatitis B
Influenza (Flu)
Pneumonia (Pneumovax)
Chicken pox (Varavax)
Shingles (Zostavax)
Meningitis
Do you have any allergies?
Yes
No
If yes, please list.
Do you have any drug allergies?
Yes
No
If yes, please list.
Have you had any recent change in your health? If Yes please explain.
Family History
Rows
Mother
Father
Sibling
Children
Mat. Grandparent
Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Austism
Bipolar disease
Surgical History
Rows
Yes
No Satisfied
Appendix Removal
Breast Lumpectomy
Facial Surgery
Hysterectomy
Phalloplasty
Gastroenterology Related Medical History
Rows
Past condition
Ongoing condition
N/A
Irritable Bowel Syndrome
Crohn's
Ulcerative colitis
Peptic Ulcer disease
GERD (reflux)
Celiac disease
Cardiology Related Medical History
Rows
Past condition
Ongoing condition
N/A
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other
Endocrine Related Medical History
Rows
Past condition
Ongoing condition
N/A
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic syndrome (pre-diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovarian Syndrome
Infertility
Weight gain
Weight loss
Eating disorder
Other
Nephrology Related Medical History cont.
Rows
Past conditon
Ongoing condition
N/A
Kidney stones
Gout
Interstitial cystitis
Frequent urinary tract infections
Frequent yeast infections
Erectile dysfunction
Sexual dysfunction
Other
Orthopedics Related Medical History
Rows
Past condition
Ongoing condition
N/A
Osteoarthritis
Fibromyalgia
Chronic pain
Other
Immune System Related Medical History
Rows
Past condition
Ongoing condition
N/A
Chronic Fatigue Syndrome
Autoimmune disease
Rheumatoid arthritis
Lupus SLE
Immune deficiency disease
Severe infectious disease
Poor Immune function
Other
Lung Related Medical History
Rows
Past condition
Ongoing condition
N/A
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Other
Dermatologic History
Rows
Past condition
Ongoing condition
N/A
Eczema
Psoriasis
Acne
Melanoma
Skin Cancer
Other
Cancer History
Rows
Past condition
Ongoing condition
N/A
Lung cancer
Breast cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer
Other
Mental Health Condition History
Rows
Past condition
Ongoing condition
N/A
Depression
Anxiety
Bipolar disorder
Schizophrenia
Headaches
Migraines
ADD/ADHD
Autism
Memory problems
Dementia/Alzheimer's
Parkinson's disease
Multiple Sclerosis
Seizures
Other
Do you currently use GLP -1 injections ?
When did you start using GLP -1
Which GLP-1 medication do you take?
What dosage GLP - 1 do you take and how how often do you inject GLP 1?
Gynecological History
Rows
Present use
Past use
Never
Birth control pills
Hormonal patches
Nuva Ring
Condom
Diaphragm
Hormonal IUD
Non-hormonal IUD
Partner Vasectomy
Gynecological History continued:
Fibrocystic breasts
Endrometriosis
Fibroids
Infertility
Painful periods
Heavy Periods
PMDD
Post Partum Depression
Gestational Diabetes
Toxemia
Baby over 8 pounds
Menopausal patients
Hot flashes
Mood Swings
Concentration/Memory problems
Vaginal dryness
Decreased libido
Headaches
Weight gain
Loss of control of urine
Palpitations
Difficulty sleeping
Please list any significant physical trauma you've experienced
Men's history
Prostate enlargement
Prostate infection
Change in libido
Impotence
Difficulty obtaining an erection
Difficulty maintaining an erection
Frequent urination at night
Urgency/Hesitancy/change in stream
Loss of urine control
Other
Dental history
Silver Mercury filling
Gold fillings
Root canals
Implants
Tooth pain
Bleeding gums
Gingivitis
Floss regularly
Medications
Emergency Contact:
First Name
Last Name
INSURANCE REQUIREMENT: All patients require travel insurance which may be included in your insurance at home or may need to be purchased through your travel agent, insurance company, etc. The required insurance is not related to your procedure in Mexico. The coverage is for any injury or illness that occurs while in Mexico including a surgical complication that you were unaware of or wasn't disclosed. Prior to your travel please provide the details of your coverage, including insurer, policy number, contact information, etc. A copy of the front and back of your card should be fine.
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