Medical Questionnaire

 

Medical Questionnaire Form

(for Executive Physicals Screening)

Please complete the following information in order for the Medical Center to make an appropriate recommendation as to the type of executive physical program best suited to your medical needs. The finest American physicians and the hospital representatives will review your medical questionnaire form, provide a free assessment of your health care needs and make appropriate recommendations.

You may complete this form online and email it to us by clicking the Submit button at the bottom of this form when done. Or, please feel free to print this form and fax it or mail it to us as follows:

Phone: 310-435-3302 (for any questions)
Facsimile (fax): 818-591-2713

By postal mail:
International Medical Care, Inc.
11901 Santa Monica Blvd., Suite #550
Los Angeles, CA 90025 USA

International Medical Care will immediately reply to your email, fax or letter with the approximate length of stay and the program rates that specifically meet your needs.

Follow this link to go to the Registration/Communications Form instead.


Title:  None  Mr.  Ms.  Mrs.  Miss  Dr.

First Name
Last Name
Date Of Birth
Company Name ( if Applicable )
Address 1
Address 2 (Optional)
City
State/Province
Country
Zip/Postal Code
Email Address (if available)
Phone Number
Facsimile "Fax" Number

1.) Have you had a family history of any of the following diseases:

Colon Cancer? Yes  No
If yes, please specify (family members, dates of treatment)
Coronary Heart Disease? Yes  No
If yes, please specify (family members, dates of treatment)

The next two questions are for women only:

Breast Cancer? Yes  No
If yes, please specify (family members, dates of treatment)
Osteoporosis? Yes  No
If yes, please specify (family members, dates of treatment)

2.) When was the last time you had any of the following tests and what were the results (if none, leave blank):

a. Date of last treadmill test ("stress test")
Results were: Normal  Abnormal
b. Date of last flexible sigmoidoscopy
Results were: Normal  Abnormal
c. Date of last chest X-rays
Results were: Normal  Abnormal
d. Date of last eye examination
Results were:
No eye problem identified.
Needed corrective lenses or new prescription.
Other result. (explain below)
Explain eye condition:

These questions are for women only:

e. Date of last mammography
Results were: Normal  Abnormal
f. Date of last Pap Smear
Results were: Normal  Abnormal

3. Within the last six months, have you experienced any type of chest pain?
Yes  No

4. Do you currently or have you ever smoked?
Yes  No If yes, on average, how many cigarettes do you currently smoke per day?

Describe your smoking history (include number of years as a smoker, quantity of cigarettes smoked per day)

5. Have you ever had surgery?
Yes  No Please specify condition and date(s) of surgery:

6. Are you currently being treated for any type of health problem?
Yes  No
Please specify condition, treatment program and prescribed medications:

7. Please describe any particular health concerns or symptoms you are currently experiencing:


Thank You for completing the information above. Clicking the "Submit Form Now"button below will email us your information and return a confirmation to your browser. After reviewing the confirmation, click the "Back" button on your browser to return to the previously viewed page.

Clicking the "Clear Form Contents" button will cause all information you typed in the above form to be cleared (removed), and the form will be reset to default values. Clicking on "Return to Index" below will return you to our home page and will not submit the above form.

   

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This page was last updated June 24, 2008
and is located at http://www.internationalmedical.com/medform.html