International Surgery
Discounts, Inc.
Shopping the world to
help America's uninsured
MEDICAL
- DENTAL
-
SURGERY -
MEDICATIONS
Questions? Comments?
Customer Service is
Available 24/7/365
24
hours a day
7 days a week
365 days a year
Email...
InternationalSurgeries@yahoo.com
Phone...800-771-3325
Note... PayPal
is not
available for any
medication program.
Free, No Obligation, Confidential, Comprehensive Price Quote
To begin the process of getting more information and a more complete and specific quote, please copy, complete and submit this form. Your answers on this form will help the international provider to better understand your medical concerns and conditions. This form will NOT be put directly into your medical chart. If you are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details. Once this form is complete, please email it to internationalsurgeries@yahoo.com or fax it toll free to 866-380-6337. Thank you!
CONFIDENTIAL ADULT MEDICAL HISTORY FORM
Name:
Date:
Address:
E-mail (write clearly):
Phones....Home Work Cell
Procedure(s) requested?
When (month/date) are you interested in getting the procedures completed?
Please write a short description of why you are interested in traveling internationally to get your medical procedures completed.
Gender: __ M/F Age: Height: Weight:
How would you rate your general health? ___ Excellent ___ Good ___ Fair ___ Poor
REVIEW OF SYMPTOMS: Please check any CURRENT symptoms you have.
Constitutional Gastrointestinal
___ Fevers/sweats/weakness ___ Blood in stool
___ Unexplained weight loss/gain ___ Nausea/vomiting/diarrhea
Ears/Nose/Throat/Mouth Genitourinary
___ Difficulty hearing/ringing in ears ___ Nighttime urination
___ Hay fever/allergies ___ Leaking urine
___ Unusual vaginal bleeding
Cardiovascular ___ Discharge: penis or vagina
___ Chest pain/discomfort
___ Palpitations Musculoskeletal ___ Muscle/joint pain
Breast ___ Breast lump/nipple discharge Skin ___ Rash/new or change in mole
Respiratory ___ Cough/wheeze Neurological ___ Headaches
___ Memory loss
Psychiatric ___ Anxiety/stress Blood/Lymphatic ___ Unexplained lumps
___ Sleep problem ____ Easy bruising/bleeding
___ Depression
In the past month, have you had little interest or pleasure in doing things, or felt low, depressed or hopeless? ___ Yes ___ No
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc.
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ALLERGIES or REACTIONS TO MEDICINES:
HEALTH MAINTENANCE SCREENING TESTS:
Lipid (cholesterol) Date __________ Abnormal? ___ Yes ___ No
Sigmoidoscopy _____ or Colonoscopy _____ Date _____ Abnormal? ___ Yes ___ No
Women: Mammogram _____ Date _____ Abnormal? ___ Yes ___ No
Pap Smear _____ Date _____ Abnormal? ___ Yes ___ No
Men: PSA (prostate) _____ Date _____ Abnormal? ___ Yes ___ No
PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following medical problems (with dates).
___ Heart disease ___ High blood pressure ___ High Cholesterol
specify type _____ ___ Diabetes ___ Thyroid problem
___ Heart attack ___ Other: (Specify):______________
SURGICAL HISTORY: Please list all prior operations (with dates).
FAMILY HISTORY: Please indicate the current status of your immediate family members:
Please indicate family members (parent, sibling, grandparent, aunt or uncle) with any of the following conditions:
Alcoholism _______________________ High Cholesterol ___________________
Cancer, specify type ________________ High Blood Pressure ________________
Heart Attack ______________________ Stroke ___________________________
Depression/Suicide _________________ Other: ____________________________
Diabetes: -----------------------------------
SOCIAL HISTORY
Tobacco Use
Cigarettes ___ Never ___ Quit Date ________________________
If Current Smoker: packs/day _____ # of yrs ________
Other Tobacco: ___ Pipe ___ Cigar ___ Snuff ___ Chew
Are you interested in quitting? ___ No ___ Yes
Alcohol Use
Do you drink alcohol? ___ No ___ Yes # drinks/week ___________
Is your alcohol use a concern for you or others? ___ No ___ Yes
Drug Use
Do you use any recreational drugs? ___ No ___ Yes
Have you ever used needles to inject drugs? ___ No ___ Yes
Other Concerns
CAFFEINE Intake: ___ None ___ Coffee/tea/soda _____ cups/day
WEIGHT: Are you satisfied with your weight? ___ No ___Yes
DIET: How do you rate your diet? ___ Good ___ Fair ___ Poor
Do you eat or drink 4 servings of dairy or soy daily or take
Calcium supplements? ___ No ___ Yes
EXERCISE: Do you exercise regularly? ___ No ___ Yes
What kind of exercise? __________________________________
How long (minutes) __________ How often? ___________
If you do not exercise, why? ______________________________
SAFETY:
Do you use car seatbelts consistently? ___ No ___ Yes
Is VIOLENCE at home a concern for you? ___ No ___ Yes
Have you ever been ABUSED? ___ No ___ Yes
SOCIOECONOMICS
Occupation: __________________________ Employer:_____________________________
Years of education/highest degree: _________________________________________________
Marital Status: Single Partner/Married / Divorced / Widowed / Other: _____________________
Spouse/partner’s name: _________________ Number of children/ages:_________________
Who lives at home with you? ______________________________________________________
WOMEN’S HEALTH HISTORY:
# pregnancies _____ # deliveries _____ # abortions _____ # miscarriages_____
1st day of most recent period: ______
Additional Information
Fax form toll free (866) 380-6337
