Medical Questionnaire - AMZA Health

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About
Specialties
Doctors
The Facility
Rehabilitation & Physical Therapy
Medical Tourism
Gallery
Blog
Contact

Medical questionnaire

Step 1 of 5

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Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

What Services Are You Interested In?

How soon would you like to book your appointment?(Required)

Specialty(Required)

Desired Procedure(Required)

Preferred Language(Required)

About You

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(Required)

I consent to receive text messages from AMZA Health, including offers and other information, which may be sent using automated technology, to the number provided. Message and data rates may apply. Consent is not required for purchase.

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Personal Details

Please ensure that all information provided about your medical history is accurate and complete. Identifying any health issues upfront allows our surgeons to recommend the necessary steps for safely proceeding with your desired procedure.

Age(Required)

Date of Birth(Required)

Gender(Required)

Weight in Lbs(Required)

Must be at least 100

Height in Feet(Required)

Inches(Required)

Marital Status(Required)

Occupation(Required)

How would you describe your daily activity level?(Required)

Do you currently have a valid passport?(Required)

Yes

No

Are you planning to travel with a companion?(Required)

Yes

No

Plastic Surgery Related Questions

Are you interested in breast surgery? *(Required)

Yes

No

Please describe your concerns and goals for each area you are considering for plastic surgery.(Required)

Medical History

Was this treatment recommended by a doctor?(Required)

Yes

No

Have you undergone any blood tests in the past 60 days?(Required)

Yes

No

Have you had any previous surgeries?(Required)

Yes

No

Have you ever experienced complications with anesthesia?(Required)

Yes

No

Do you have any known allergies?(Required)

Yes

No

If yes, please list them below

Have you ever been pregnant?(Required)

Yes

No

Do you consume alcohol?(Required)

Yes

No

If yes, please specify frequency

Do you smoke?(Required)

Yes

No

If yes, please specify frequency

Do you have any diagnosed illnesses or medical conditions?(Required)

Yes

No

Have you been diagnosed with Diabetes?(Required)

Yes

No

Do you have any Heart Disorders?(Required)

Yes

No

Do you suffer from High Blood Pressure?(Required)

Yes

No

Do you have High Cholesterol?(Required)

Yes

No

Have you experienced issues related to Gout?(Required)

Yes

No

Do you have a Kidney or Urinary Disorder?(Required)

Yes

No

Do you suffer from Gallstones?(Required)

Yes

No

Have you been diagnosed with Sleep Apnea?(Required)

Yes

No

Do you suffer from Asthma?(Required)

Yes

No

Do you have Dermatitis or Eczema?(Required)

Yes

No

Do you have any Orthopedic conditions or injuries?(Required)

Yes

No

Do you have Breathing or Respiratory issues?(Required)

Yes

No

Have you been diagnosed with a Neurological or Psychological Disorder?(Required)

Yes

No

Do you experience Reflux, Heartburn, or Gastritis?(Required)

Yes

No

Have you been diagnosed with Ulcers?(Required)

Yes

No

Do you have Hepatitis or Liver Disease?(Required)

Yes

No

Do you have Anemia or a Bleeding Disorder?(Required)

Yes

No

Do you suffer from Varicose Veins or experience Leg Swelling?(Required)

Yes

No

Have you been diagnosed with Epilepsy?(Required)

Yes

No

Do you suffer from Rhinitis?(Required)

Yes

No

Do you have difficulty swallowing or experience recurring sore throats?(Required)

Yes

No

Do you experience a hoarse voice or persistent nighttime coughs?(Required)

Yes

No

Have you been diagnosed with HIV or any other infectious diseases?(Required)

Yes

No

Have you had any significant illnesses in the past 5 years?(Required)

Yes

No

If yes, please list them below

Have you taken any medications in the past 12 months?(Required)

Yes

No

If yes, please list them below

Upload Photos for Review

To ensure our plastic surgeons can thoroughly evaluate your case, we kindly ask you to submit clear photos of yourself along with your completed medical questionnaire. These photos will help our surgeons determine if you are a suitable candidate for surgery and recommend the most optimal procedures based on your goals and physical attributes.

If you’re unable to upload your photos right now, don’t worry! You can return to upload them later. However, please try to submit them promptly, as our surgeons require them to complete your case review.

Upload photos(Required)

Drop files here or

Max. file size: 10 MB.

Final Step: Signature and Submission

You’re almost done! Don’t forget to click Submit!

Once you click Submit, your Care Manager will receive your completed file and review it with our doctors. You will be contacted within 24-48 hours with their recommendations.

Before submitting, please read the statement below carefully and ensure all information provided is accurate and complete:

Declaration:

By clicking "Submit," I affirm that all the information provided in this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that the medical personnel, including but not limited to physicians, nurses, and technicians, will rely on the truth, accuracy, and completeness of this information when exercising their medical judgment.

Name

This field is for validation purposes and should be left unchanged.

Meet the experts at AMZA Health, leaders in medical tourism in Tijuana, Mexico. Our team of board-certified doctors and surgeons is dedicated to delivering exceptional care in a state-of-the-art facility, backed by inspiring patient success stories. Start your journey to world-class healthcare and a healthier, happier life today!

Navigation

Home
About
The Facility
Doctors
Rehabilitation & Physical Therapy
Medical Tourism
Gallery
Blog
Contact

Home
About
The Facility
Doctors
Rehabilitation & Physical Therapy
Medical Tourism
Gallery
Blog
Contact

Specialties

Orthopedic and Traumatology
Bariatric
Imaging Center
Fertility
- IVF (In vitro Fertilization)
Hair Transplant
- Hair Transplant
Plastic Surgery
General Surgery
Dental care
Regenerative Medicine

Orthopedic and Traumatology
Bariatric
Imaging Center
Fertility
- IVF (In vitro Fertilization)
Hair Transplant
- Hair Transplant
Plastic Surgery
General Surgery
Dental care
Regenerative Medicine

Contact Us

Contact@amzahealth.com

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