Hospital Jerusalem

Patient Questionnaire

Name: Date:
*
Phone number: Cellphone number:
Address:  
Email:
 
Weight: Height: BMI: Age:
pounds Ft. In.
 
Surgical date: Doctor:
Procedure(s): Would you like a free dental and vision exam ?
 
Person traveling with you: Relationship:
Please check the following conditions that apply to you:
Anemia Pregnant Heart disease Seasonal allergies
Asthma Indigestion Ankle swelling Painful urination
Cancer Constipation Tuberculosis Difficult urination
Headaches Diarrhea Sleep apnea Shortness of breath
Diabetes 1 Acid reflux Bruise easily Confusion / depression
Diabetes 2 Glacoma Hypertension Difficulty swallowing
Epilepsy Convulsions Freq. nausea Gall Bladder problems
Ulcers Paralysis Liver problems Mental disorder / bi-polar
Vomiting Pneumonia Low back pain Unusual lumps, bumps or masses
Chest Pain Sore throat C-pap machine Lung problems / congestion
 
Please explain about your previous medical conditions ( if selected ).
 
Alcohol:
Drug use:
Tobacco use:
 
Previous surgeries and hospitalizations:

Current medications:
Medication, Usage, Dosage, How often
 
Latex allergy:
Drug allergies:
Food allergies:
THE PERSON LISTED BELOW WILL BE YOUR HOME CONTACT PERSON.
WE WILL NOT RELEASE ANY INFORMATION TO ANYONE WHO IS NOT LISTED.
Agree:  
Please contact: after my surgery at:
IN CASE OF EMERGENCY
Please list the person(s) name, phone number and relationship to you.
Please list any health issues that were not addressed in the medical information above.
Procedure
Procedure quote: Deposit paid:
$ $
Type of balance payment: Note for Canadian patients
Travelers checks or wire transfers ONLY
   
Sign with your initials if all is true:
 
Thank you for selecting our services.
Please feel free to contact our office with any questions you may have.
 
     

Patient Liaison

Louise Johnson
Available 24/7 for your convenience !

Toll Free:+1 866 806 4286
Direct #:+1 727 423 5662
FAX:+1 772 324 8336
E-mail:info@hospitaljerusalem.com.mx