Patient Data Form

Please fill out the form below and click on the “Submit” button at the base of the form. All fields marked with an asterisk (*) must be provided before the application is allowed to be saved.

1. First Name *

2. Last Name

3. Date of Birth *

4. Sex

5. Home Address

6. Phone *

7. Email *

8. Country *

9. Nationality

10. What is the nature of the Illness/Condition/Request? *

11. How did the Illness/Condition originate?

12. How long has the Illness/Condition existed? (Years|Months|Days)

13. If applicable, what Stage is the Illness/Condition?

14. State any existing Allergies

15. Have there been previous surgery/treatment for the Illness/Condition? If Yes, please describe

16. State any medicine or drugs presently being taken. (Either related or unrelated to the Illness/Condition)

17. Does the client presently or have a history of any other associated or unrelated Illness/Condition? If Yes, please state

18. Describe any Physical Limitations that exist. E.g. Paralysis, Disability, etc

19. Are Item 18 issues as a result of Illness/Condition?

20. Does the client have Ulcers or Bed Sores? If Yes, describe where?

21. If Cancer was diagnosed was a Biopsy done? If Yes, what are the results?

22. Does the client have relevant Health Insurance? If Yes, who is the provider?

23. What is the specific Request of the Client? - A Second Opinion? A Proposal for Solution/Treatment?

24. What is the desired Time Frame for Travel for Medical Attention?

25. Does the client require and Air Ambulance?

26. Does the client have Medical Records for review?

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