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FastTrack – To speed the facilitation of your medical services

ALL INFORMATION IS KEPT ABSOLUTELY CONFIDENTIAL

YES, I WANT TO GET MY MEDICAL/DENTAL WORK COMPLETED AS QUICKLY AS POSSIBLE

Your Name (required)

I am Interested in ? (Treatment/Tour)

Your Email (required)

Home Phone (required)

Cell phone Phone

Date Of Birth

Do you have a valid passport that will remain valid for at least 6 months?
 Yes No

Gender

Height (feet inches)

Present Weight (Pounds)

What is the best time to call you?

Have you had, or do you have, any of the following illnesses or symptoms?

Heart Disease
 Yes No

High Blood Pressure
 Yes No

Angina
 Yes No

M.I.(myocardial infarction)
 Yes No

CABG(coronary artery bypass graft)
 Yes No

High Cholesterol
 Yes No

Medication
 Yes No

List of all meds taken regularly

Diabetes
 Yes No

Neuropathy
 Yes No

Abnormal EKG
 Yes No

Diabetes
 Yes No

Stress test to rule out cardiac problems
 Yes No

High Triglycerides
 Yes No

Asthma
 Yes No

Trouble sleeping
 Yes No

Shortness of Breath
 Yes No

Last fasting blood sugar
 Yes No

Morning Headaches
 Yes No

Daytime drowsiness
 Yes No

Restless sleep
 Yes No

Snoring
 Yes No

Awakening at night
 Yes No

Observed apneas
 Yes No

Sleep apnea syndrome
 Yes No

Last sleep study, CPAP used
 Yes No

Heartburn/hiatus hernia
 Yes No

Hepatitis
 Yes No

Blood Transfusion
 Yes No

AIDS/HIV exposure
 Yes No

Colitis
 Yes No

Kidney Disease
 Yes No

Bleeding abnormality
 Yes No

Thyroid problems
 Yes No

Gall bladder disease
 Yes No

Low back strain/pain/sciatica
 Yes No

Pain in hips/knees/ankles/feet
 Yes No

Allergy to medication?
 Yes No

List medication and reaction.

Leakage of urine with laughing/coughing/sneezing
 Yes No

Please list below all serious and hospitalization you have experienced
in adulthood: Major Illness /Surgery Date and Treatment.

SOCIAL HISTORY

Do you use tobacco currently?
 Yes No

Do you drink beer,liquor,or wine?
 Yes No

Do you use any recreational drugs?
 Yes No

Who usually prepares the food you eat at home?
 Yes No

What exercise do you do on regular basis?

Please list your activities (out of home):

Hear about from? (Reference)

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