Goa Health Travel Application Form

Goa-Health-Travel Application Form


Privacy Statement : We respect your privacy and therefore all details provided will be kept safely and not be passed on to third parties without your permission.

Required fields are denoted by *

Patient Information

First name :

Middle name :

Last name :

Address :

City :

State/County :

Country :

Zip/Postcode:

Telephone no.'s :

Home :

Mobile :

Office :

Fax :

E-mail address :

Other information :

Date of birth :

* * *

Age :

Height :

Weight :

Gender :

Marital status :

For U.S. residents only. Social Security no. :

Emergency contact information :

Name :

Phone no. :

E-mail address :

Enter If Applicable

Referring physician (or source of reference) :

Address :

Phone no. :

E-mail address :

Family physician/GP information :

Name :

Address :

Phone no. :

E-mail address :

Patient Medical Information/History

Your health is of extreme importance to us. In order for us to best prepare for your visit, the more we know about you, the better we can assist you. Please complete the following information as completely as possible.

What procedure or procedures are you considering? ( please be as specific as possible )

How long has this
concerned you?

Have you had any previous treatment for this?

If YES, how and when was this treated?

Review of systems :

Do you have or have you had any of the following (Please check YES or NO).

AIDS or HIV positive :

Anemia :

Arthritis :

Asthma :

Back problems :

Blood clots in legs :

Blood disorders :

Bleeding problems :

Breathing problems :

Cancer :

Chest pains :

Colitis :

Diabetes :

Ear problems :

Eye problems :

Epilepsy :

Heart problems :

Heart murmur :

Heart palpitations :

Hepatitis :

High blood pressure :

Irregular heart beat :

Kidney problems :

Migraine headaches :

Nervous breakdown :

Nose/throat problems :

Pneumonia :

Psychiatric condition :

Rheumatic fever :

Seizures :

Shortness of breath :

Skin cancer :

Stomach problems :

Stroke :

Thyroid problems :

Tuberculosis :

Transfusion :

Are you pregnant?

If so, please indicate how far along.

Are you lactating?

Do you suffer from Osteoporosis?

Patient Past, Family and History

Please list any prior hospitalizations and/or pervious surgery, including dates

Are you allergic to or have you ever had a reaction to any medication or drug; local anesthetic; or general anesthetic?

If so, please list medication and type of reaction

Are you now or have you ever taken any medication regularly?
(aspirin, birth control pills, prescribed medications, herbs, vitamins etc.)

Currently taking

Previously taken

Do you wear glasses or contact lenses?

Current prescription?

Do you have problems with dry eyes?

Do you use wetting drops?

If YES, how often, and for how long have you been using them?

Are you now or have you ever taken a prescription or over-the-counter medication for allergies, stuffiness, difficulty breathing, sinus problems or other nasal problems?

If YES, Please list :

Do you currently smoke?

If YES, how many cigarettes per day

If YES, how many years

Have you ever smoked?

If YES, how many cigarettes per day

If YES, how many years

Do you drink alcohol regularly?

Do you have any relatives who have had breast cancer?

Have you ever had a mammogram?

If YES, when was your last one?

Radiation

Excessive sun

Do you or a family member have difficulty with prolonged bleeding when cut?

Do you or a member of your family bruise easily?

Do you have a problem with excessive scarring or keloid formation after being cut?

Have you or a member of your family ever had a problem with anesthesia?

Is your general health good?

Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist, psychologist or mental health counselor?

Thank you for taking the time to complete this information. It will be reviewed by our consulting physicians and your selected specialists in order to help them determine the most appropriate course of treatment for you. They or We will contact you should further information and/or clarification be required.

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Required fields are denoted by *

Privacy Statement : We respect your privacy and therefore all details provided will be kept safely and not be passed on to third parties without your permission.