Exodus Medical - Website developed by robertosolorzano.com

Call Us Toll Free:
Direct Line:
Skype:

1(877) 789-5272
(559) 723-6484
sokoro72

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Patient History Form
THE INFORMATION SUBMITTED BY YOU IS PRIVILEGED AND CONFIDENTIAL

Name:

Date:

Phone number:

Cellphone number:

Address:

Email:

Weight:

Height:

BMI:

Age:

pounds

Ft. In.

Surgical date:

Doctor:

Procedure(s):

Would you like a free dental and vision exam ?

Yes

Person traveling with you:

Relationship:

Please check the following conditions that apply to you:

Anemia	Pregnant	Heart disease	Seasonal allergies
Asthma	Indigestion	Ankle swelling	Painful urination
Cancer	Constipation	Tuberculosis	Difficult urination
Headaches	Diarrhea	Sleep apnea	Shortness of breath
Diabetes 1	Acid reflux	Bruise easily	Confusion / depression
Diabetes 2	Glacoma	Hypertension	Difficulty swallowing
Epilepsy	Convulsions	Freq. nausea	Gall Bladder problems
Ulcers	Paralysis	Liver problems	Mental disorder / bi-polar
Vomiting	Pneumonia	Low back pain	Unusual lumps, bumps or masses
Chest Pain	Sore throat	C-pap machine	Lung problems / congestion

Please explain about your previous medical conditions ( if selected ).

Alcohol:	None	Minimal	Moderate	Heavy
Drug use:	None	Minimal	Moderate	Heavy
Tobacco use:	None	Minimal	Moderate	Heavy

Previous surgeries and hospitalizations:

Current medications:

Medication, Usage, Dosage, How often

Latex allergy:

Yes

Drug allergies:

Food allergies:

THE PERSON LISTED BELOW WILL BE YOUR HOME CONTACT PERSON.
WE WILL NOT RELEASE ANY INFORMATION TO ANYONE WHO IS NOT LISTED.

Agree:
Yes	No

Please contact: after my surgery at:

IN CASE OF EMERGENCY

Please list the person(s) name, phone number and relationship to you.

Please list any health issues that were not addressed in the medical information above.

Procedure

Procedure quote:

Deposit paid:

Type of balance payment:

Note for Canadian patients

Travelers checks or wire transfers ONLY

Sign with your initials if all is true:

Thank you for selecting our services.
Please feel free to contact our office with any questions you may have.

Exodus Medical
info@exodusmedical.com


Patient Liaison

		Socorro Mercado Toll free number: (877) 789-5272 Direct line: (559) 723-6484 Hablo Español

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