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) By postal mail: 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:
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This page was last updated June 24, 2008
and is located at https://www.internationalmedical.com/medform.html