Medical Form - International Patient Facilitators

Personal Information

Procedure

Patient Facilitator's Name

Full Name*

Email*

Sex

Age*

Height*

Weight*

BMI

Date of Birth (dd/mm/yy)

Telephone*

Cell Phone

Address

City

State

Zip

Other Information

Maximum Weight

Date at Max Weight?

Date Of Surgery

List All Medecine Allergies

Name of Person to Contact (In Case Of Emergency)

Emergency Phone

Questionnaire

Do you have any medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurogical disorders, etc)?

Yes
No
Don Not Know

If Yes, please list:

Are you currently taking any medications or herbal supplements

Yes
No
Do not Know

If Yes, please list the name, dosage and reason for this medicine:

Is there any history in your family of diabetes, cancer and/or hypertension?

Yes
No
Do not Know

If Yes, please indicate which ones:

Have you had any surgeries (i.e., galibladder, appendix, hernia, heart, etc.)?

Yes
No
Do not Know

If Yes, please list:

Do you have any adverse reactions to anesthesia?

Yes
No
Do not Know

If Yes, please indicate the reaction:

Do you have dentures, dental implants, or caps?

Yes
No
Do not Know

If Yes, please indicate where:

Do you have any children?

Yes
No

If Yes, how many?

Do you have heavy periods?

Yes
No
Do not have periods

Do you smoke?

Yes
No

If Yes, how many cigarettes a day?

Do you drink?

Yes
No

If Yes, how much and how frequently?

Do you do drugs?

Yes
No

If Yes, what kind and how often?

FOR THE FOLLOWING QUESTIONS, PLEASE INDICATE "YES" "NO" OR "DO NOT KNOW".

* PLEASE ANSWER ALL OF QUESTIONS.

1. Do you currently take any of the following medications

a) Aspirin (Excedrin, Anacin, Bufferin)

Yes
No
Do not Know

b) Anticoagulants (blood-thinning medicine)

Yes
No
Do not Know

c) Propanol Verapamil (heart rhythm medicines)

Yes
No
Do not Know

d) Diuretics (water pills)

Yes
No
Do not Know

e) Antihypertensive Drugs (blood pressure pills)

Yes
No
Do not Know

f) Digitalis (heart pills)

Yes
No
Do not Know

g) Steroids (prednisone, cortisone)

Yes
No
Do not Know

2. Have you ever been treated for cancer with chemotherapy or radiation therapy?

Yes
No

If Yes: when:

3. Do you currently have any problems with your:

a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)

Yes
No
Do not Know

b) Kidneys (infection, stones, failure)

Yes
No
Do not Know

c) Spleen

Yes
No
Do not Know

d) Blood (anemia, leukemia)

Yes
No
Do not Know

d) Blood (anemia, leukemia)

Yes
No
Do not Know

4. Have you or anyone in your family ever had a serious bleeding problem?

Yes
No
Do not Know

5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?

Yes
No
Do not Know

6. Do your gums bleed when you brush your teeth?

Yes
No
Do not Know

7. Are you pregnant?

Yes
No
Do not Know

8. Is there a possibility that you are pregnant?

Yes
No
Do not Know

9. Have you been told you have diabetes?

Yes
No
Do not Know

10. Do you wake up to urinate more than once at night?

Yes
No
Do not Know

11. Do you have muscle cramps or pains?

Yes
No
Do not Know

12. Do you have problems with your lungs or chest? (e.g. chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day, shortness of breath, emphysema, asthma, bronchitis)

Yes
No

If Yes: please list:

13. Do you have a cough, or cough frequently?

Yes
No
Do not Know

14. Do you have epilepsy, or suffer from fits or seizures?

Yes
No
Do not Know

15. Do you have neck or back problems?

Yes
No
Do not Know

15. Do you have neck or back problems?

Yes
No
Do not Know

16. Are you scheduled to have an operation?

Yes
No

If Yes: what operation?