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Patient Medical Questionnaire
Desired Procedure
Preferred Surgery Date
Personal information
First Name
Last Name
Gender
Date Of Birth
Age
Do you have a valid passport?
Occupation
Preferred Language
Contact information
Email
Telephone
Home Address
Country
State
City
Zip Code
Medical History
Why is the Treatment required?
Was the Treatment recommended by a doctor?
Have you had any imaging/studies already performed?
Have you had any blood tests already performed in the past 30 days?
Yes No
Current Weight
Height:
BMI
Marital Status
What is your typical job activity level?
Have you had any previous surgeries?
Surgery
Date
Reason
Do you have any anesthesia problems?
Explain
Do you have any allergies? (Please list all)
Explain
Have you had any pregnancies?
Explain
Do you drink alcohol? (Frequency)
Frequency:
Do you smoke?(Frequency)
Frequency:
Do you have diabetes?
Explain
Do you have a Heart Disorder?
Explain
Do you suffer from High Blood Pressure?
Explain
Do you have High Cholesterol?
Explain
Do you have any Gout problems?
Explain
Do you have a Kidney or Urinary Disorder?
Explain
Do you suffer from Gallstones?
Explain
Do you suffer from Sleep Apnea?
Explain
Do you suffer from Asthma?
Do you suffer from Dermatitis Eczema?
Explain
Do you have any orthopedic problems?
Explain
Do you have Breathing/Respiratory problems?
Explain
Do you have a Neurological or Psychological Nervous Disorder?
Explain
Do you suffer from Reflux, Heartburn, and/or Gastritis?
Explain
Do you have ulcers?
Explain
Do you have Hepatitis or Liver Disease?
Explain
Do you have Anemia or a Bleeding Disorder?
Explain
Do you suffer from Varicose Veins or Leg Swelling?
Explain
Do you suffer from epilepsy?
Explain
Do you suffer from Rhinitis?
Explain
Do you have difficulty swallowing or recurring sore throat?
Explain
Do you suffer from a hoarse voice or regular cough at night?
Please answer the following questions if inquiring about Weight-Loss Surgery
Did you have Diabetes while pregnant?
Explain:
Have you done any special diets to try to lose weight?
Explain:
Are you on any special diet (Vegan, Vegetarian)?
Explain:
Have you taken Appetite Suppressant?
Explain:
Any other weight-loss drug treatment?
Explain:
Did other events lead to weight gain?
Explain:
Fertility Evaluation Show
How long have you been trying to conceive?
At what age did your menstrual cycle begin?
What is your average menstrual cycle length?
Do you have pain during your menstrual cycle or intercourse?
Explain:
How is it?
Start date of your last 2 menstrual cycles
Have you used contraceptives?
Explain:
Have you had children before?
How many:
Age of last one:
How many with current partner?
Have you had miscarriages?
Explain:
Have you had D & Cs?
How many?
State reasons and results:
PARTNER INFORMATION
First Name
Last Name
Age
Is this your first partner?
Has your partner had children previously?
How many?:
INFERTILITY PROBLEM
Briefly explain your fertility problem(s)
Have you been diagnosed with fertility issues? What was the diagnosis and treatment(s) given?
Were you helped by an Infertility specialist? If so, where?
Explain:
Have you had abdominal surgeries?
Explain:
Have you had studies to evaluate your uterus and tubes? What were the results?
Explain:
Select lab tests performed
Do you ever been diagnosed with Chlamydia, Gonorrhea or Mycoplasma?
Explain:
Do you or your partner have any other disease?
Explain:
Has your partner had semen analysis? What were the results?
Explain:
Please tell us the areas of interest
Illness History
Have you had any illnesses in the past 5 years? (Please list all)
Illness
Date
Treatment
Outcome
Medication History
Have you taken any medications in the past 12 months? (Please list all)
Name of medications
How often do you take it?
When did you start taking it?
Reason