Makewell

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The treatment of a disease may be entirely impersonal; the care
of a patient must be completely personal.

Find a Doctor, Dentist, Clinic,
Hospital or Healthcare Provider:

info@make-well.com

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Fill the QUESTIONNAIRE

Client Reference No:
Desired Procedure(s):
Name
Physical Information
Gender?	Female Male
Date of birth?
Height?
Weight?
Your contact information
Name?
Daytime phone number?
Evening phone number?
Email Address?
Your Physician Information
Name?
Address?
Phone Number?
Email address?
Medical history/Information
Do you have high blood pressure?
What is your blood pressure?
Date of last measure of your blood pressure?
Have you ever had surgery before?
If yes, what type?
Any complications?
Aids or HIV Positive?	Yes No
Anemia	Yes No
Arthritis?	Yes No
Asthma?	Yes No
Back problems?	Yes No
Blood clots?	Yes No
Blood disorders?	Yes No
Bleeding problems?	Yes No
Breathing problems?	Yes No
Cancer?	Yes No
Chest pains?	Yes No
Colitis?	Yes No
Depression?	Yes No
Diabetes?	Yes No
Ear problems?	Yes No
Heart problems?	Yes No
Epliepsy?	Yes No
Heart murmur?	Yes No
Hepatitis?	Yes No
High blood pressure?	Yes No
Irregular heart beat?	Yes No
Kidney problems?	Yes No
Migraine headaches?	Yes No
Nervous breakdown?	Yes No
Nose/throat problems?	Yes No
Osteoporosis?	Yes No
Pneumonia?	Yes No
Psychiatric condition?	Yes No
Rheumatic fever?	Yes No
Seizures?	Yes No
Shortness of breath?	Yes No
Skin cancer?	Yes No
Stomach problems?	Yes No
Stoke?	Yes No
Thyroid problems?	Yes No
Tuberculosis?	Yes No
Transfusion?	Yes No
Are you pregnant?	Yes No
Have you ever smoked?	Yes No
Do you currently smoke?	Yes No
If yes, how many years?	Yes No
If yes, how many cigarettes/day?	Yes No
Medications
Are you allergic to any medications?
If yes, give the name of the medications?
If yes, describe the allergic reaction?
Are you currently on medications?
If so, which medications?
Have you ever had problems with anesthesia?
Please describe any other issues that may need attention?

I am agree with below mentioned terms
This form assists our surgeon in the evaluation of your fitness for the desired treatment. Your privacy is guaranteed. We will ask you to sign this form upon arrival at your destination. I certify that the above information is correct and complete. I have not withheld any information that is relevant for the surgeon to judge on my medical history.