Patient Application

Personal Information

Clinic Location :
Were you referred?
Referrer's Name
Salutation * :
Legal First Name (as on license or passport) * :
Legal Middle Name (as on license or passport) :
Legal Last Name (as on license or passport) * :
Date of Birth * :
Weight (kgs) * :
Height (CM) * :
Gender * :
Address * :

Country * :
City * :

One of our physicians might need to speak with you (or the applicant's representative) personally. Please list the single best phone number to reach you, Monday - Friday, 6 PM - 3 AM, East African Time (EAT, GMT + 3).

Best Phone * :	(include area code)
Work Phone :	(include area code)
Cell Phone :	(include area code)
FAX Number :	(include area code)
Email * :
Occupation :
Marital Status * :

Parent/Guardian Information

Name :
Address :
Home Phone :	(include area code)
Office Phone :	(include area code)
Cell Phone :	(include area code)
Alternate Phone :	(include area code)

Physical Limitations

Need Assistance Walking? *	Yes No
Wheel Chair Needed? *	Yes No
Other Needs :

Emergency Contact

Name * :
Relationship * :
Phone * :	(include area code)
Address :
Address :
Country :
City :

Primary Diagnosis/Disease

Do you have active Diagnosis and Physician?	Yes No
Physician Name * :
Physician Phone :	(include area code)
Primary Disease Diagnosis and Symptoms/Medical Conditions * :
Date of Diagnosis * :
Medical Records Available?
Current Medications :
Anticoagulated?
Anticoagulated Since When :
Why Anticoagulated?

Patient History: Cancer

Have you ever been diagnosed with any type of cancer? *	Yes No
Cancer Type :
Date Cancer Diagnosed :
Cancer Status :

Patient History: Diabetes

Are You Diabetic?
Taking Insulin?

Patient History: Neurological System

Vision Decrease?
Vision Black Spots?
Vision Nistagmus?
Muscle Weakness?
Muscle Wasting?
Walking Difficulties?
Decreased Hand Strength?
Fainting?
Speech Problems?
Tingling Sensation?
Muscle Fasciculations?
Spasticity?
Hyperreflexia?
Hyporeflexia?
Depression?
Loss of Memory?
Headaches?
Sleep Disturbances?
Dizziness?

Patient History: Pulmonary System

Asthma?
Chronic Bronchitis?
Chronic Cough?
Emphysema?
Tuberculosis?

Patient History: Cardiovascular Problems

Myocardial Infarction?
Myocardial Infarction Date :
Angina Pectoris?
Tachycardia?
By-Pass Surgery?
By-Pass Surgery Date :
Hypertension (high blood pressure)?
Hypotension (low blood pressure)?

Patient History: Circulatory

Poor Arterial Circulation?
Poor Venous Circulation?
Leg Cramps?
Tired Legs?
Swollen Ankles?
Varicose Veins?
Tingling Sensation in Arms and Legs?
Falling Asleep of the Hands and Legs?
Ulcers or open wounds anywhere on your body? *	Yes No

Patient History: Gastrointestinal Problems

Acid Indigestion?
Bloating?
Stomach or Duodenal Ulcer?
Stomach or Duodenal Ulcer Date :
Loss of Appetite?
Rapid Weight Gain?
Rapid Weight Loss?
Overweight Problem?
Have You Had Upper GI endoscopy?
Upper GI Date :
Upper GI Results :
Hepatitis?
Hepatitis Type :
Gall Bladder Problems?
Gall Stones?
Icterus?
Recurring Diarrhea?

Patient History: Upper Respiratory Test

Chronic Sinusitis? *	Yes No
Allergic Sinus Problem? *	Yes No
Chronic Allergic Rhinitis? *	Yes No
Sinus Headaches? *	Yes No
Chronic Nose Bleeds? *	Yes No
Chronic Colds? *	Yes No

Patient History: Rheumatic Screen

Soft Tissue Rheumatism?
Articular Rheumatism?
Joint Pain?
Back Pain?
Rheumatoid Arthritis?
Other Rheumatic Conditions :

Patient History: Endocrinological System

Diabetes Mellitus?
Overactive Thyroid?
Underactive Thyroid?
Adrenal Gland Dysfunction?
Female Menopause?
Male Menopause?
Other Endocrinological Conditions :

Health History Allergy:

Food Allergy, Especially Eggs? *	Yes No
Hay Fever? *	Yes No
Allergic Asthma? *	Yes No
Medication Allergies? *	Yes No
Medication Allergy Symptoms :
Allergies to any vaccinations? *	Yes No

Patient History: Other

When was your last vaccination?
Do You Smoke Cigarettes? *	Yes No
Do You Smoke Cigars? *	Yes No
Do You Smoke Pipes? *	Yes No
How Much Do You Smoke Per Day?
Do you drink wine? *	Yes No
Do you drink beer? *	Yes No
Do you drink hard liquor? *	Yes No
How much do you typically drink per day?
Please list any nutritional supplements you are taking :
Other Significant or Chronic Illnesses * :
Do You Take Human Growth Hormone?
How Long Have You Taken Growth Hormone?
Human Growth Hormone Injections per Week :
PSA Test (Men Only)?
PSA Test Date :
PSA Test Result :
Periodic Mammograms (Women only)?
Mammogram Test Date :
Mammogram test result :

Surgical/Hospitalizations

Surgical Procedure 1 :
Surgical Procedure 1 Date :
Surgical Procedure 2 :
Surgical Procedure 2 Date :
Surgical Procedure 3 :
Surgical Procedure 3 Date :
Other Surgical Procedures :

Family History
Has any member of your family had any of the following:

Hypoglycemia?
Diabetes?
Thyroid Problem?
Hormone Problem?
Cancer?
High Blood Pressure?
Kidney Problem?
Heart Problem?
Leukemia?
Arthritis?
Prostate Problem?
Mental Disorder?
Anxiety?
Lung Problem?
Fatigue?
Stroke?
Do you have any questions or comments?
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I have read and understood the terms and conditions.

Patient Application

Personal Information

Parent/Guardian Information

Physical Limitations

Emergency Contact

Primary Diagnosis/Disease

Patient History: Cancer

Patient History: Diabetes

Patient History: Neurological System

Patient History: Pulmonary System

Patient History: Cardiovascular Problems

Patient History: Circulatory

Patient History: Gastrointestinal Problems

Patient History: Upper Respiratory Test

Patient History: Rheumatic Screen

Patient History: Endocrinological System

Health History Allergy:

Patient History: Other

Surgical/Hospitalizations

Family History