PRE-ADMISSION DETAILS AND MEDICAL HISTORY
  
 
 
 
( To be filled by Patient/Relative only )
 
     
     
     
 
Name of the Patient:
   
Age yrs
   
Sex
Male
Female

Transgender

 

   
Phone (res.)
   
Phone (Off.)
   
Mobile
   
E-mail
   
Fax
   
   
   
Expected date of arrival
 
(yyyy)
   
Expected date of Admission
 
(yyyy)
   
Name of the present consulting doctor/physician
   

Recent diagnosis of the doctor/physician
   
CURRENT MEDICATION
 
DRUG NAME
STRENGTH (mg)
DOSE/
FREQUENCY
     
 
DIAGNOSTIC REPORTS
 
Specifications of the tests
Year of diagnosis
Impressions
Pathology
Radiology
MRI
CT-Scan
PET-Scan
X-ray
 

Do you have any health problems?If Yes, please describe.
Yes
No
 
 

Have you had any major surgery?If Yes, please describe.
Yes
No
 
 

Have you any major injuries?If Yes, please describe.
Yes
No
 
 

Do you take any medications/nutritional supplements/herbal medications?If Yes, please describe.
Yes
No
 
 

Have you ever had any adverse reaction to local or general anesthesia?
Yes
No
 

Do You take Aspirin/Blood Thinners?
Yes
No
 

Have you had an allergic reaction to medication? If Yes, what type and what year.
Yes
No
 
 

Do you have any known allergies? If Yes, please describe.
Yes
No
 
 

Do you have any bleeding problems? If Yes, please describe.
Yes
No
 
 

Do you smoke? If Yes, how much?
Yes
No
 
 

Do you take alcohol or other recreation medicines/drugs? If Yes, please describe.
Yes
No
 
 

Are You Pregnant / Lactating? ( only for Female Patients)
Yes
No
 
 

Do you have any children? If Yes, how many, and how old is the youngest? ( only for Female Patients)
Yes
No
 
 

The following questions concern you and your family. Do you and/or any of your family member has the following medical problem?
 
SELF
Family Member
     
Yes
No
       
Neurological Disorder
       
Diabetes
       
Heart Problems
       
Breathing / Lung Problems
       
Gastrointestinal problems
       
Kidney Problems
       

skin problems/skin cancer
If Yes, please describe.
       

Other medical problems, including communicable diseases.
If Yes, please describe.
 
Insurance Coverage  
   

Do you have an Insurance Coverage?
Yes
No
If Yes, please furnish the insurance coverage details of your health insurance policy
 

I hereby declare that the facts stated above are true to the best of my knowledge and belief.
   
Terms & Conditions must be Accepted before submitting this Form
   
I accept
I do not accept
   
   
   
   
 
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