Medici Integrative Health & Surgery Center Medical Questionnare


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f you feel you are a candidate for Surgery or Diabetes Stem Cell Therapy please fill out the Medical Questionnaire below. A representative at Medici will get back back to you as soon as possible with more information.

Patient's Personal Details


Patient
E-mail Address
Phone Number
Nearest Major City
Sex
Referring Party
Height
Weight
Age
Describe Present Illness

Describe all Diseases/Illnesses since Birth


Cardiovascular
Pulmonary
Gastrointestinal
Urinary
Gynecological
Neurological
Psychiatric
Bones, Joints, Muscles
Immunological
Cancer
Eyes & Ears
Skin
Childhood
Describe all treatments, operations and body's response
Current medications and non-prescriptions
Describe all allergies to medications, chemicals, or food
Describe alcohol intake, "street" drugs, and smoking habits
Recent vaccinations or serum therapy
Recent diagnostic or therapeutic x-ray or ct scan, radioisotope
Describe any chronic infections, dental, throat, sinuses, kidneys & bladder, pelvic, intestine & colon, skin etc.
Remarks

* Required fields: Name, and e-mail address.

Contact Information




Dr. Atl No. 10050.
   Zona Urbana Río.
   Tijuana, B.C. México


info@medicicenterintegrativehealth.com