Medical Discounts, Inc.
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MEDICAL - DENTAL -
SURGERY - MEDICATIONS
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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 medicaldiscounts@aol.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.

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

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