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REASON FOR
CONSULTATION
Emergency
Confirm a Diagnosis/
Second Opinion
Seek a Diagnosis
Seek Treatment
Other
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PATIENT MEDICAL
INFORMATION
Chief Complaint / Current Diagnosis :
Previous Examination(s) Performed
X-Rays, Date :
Ultrasound, Date :
Surgery, Date :
Magnetic Resonance
Imaging (MRI),
Date :
Angiography, Date :
Scan, Date :
Other(s)
Past Medical History
(Include any relevant information
such as history of diabetes, heart
disease, past surgeries, alcohol use, tobacco use,
etc):
Current Medications
(name, dosage, frequency):
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| REFERRING PHYSICIAN INFORMATION |
| First Name :
|
| Last Name :
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Address :
|
| City :
|
| Country :
|
| Postal Code : |
| Specialty :
|
| Telephone(s) : |
| Fax :
|
| E-mail :
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DOES THE PATIENT REQUIRE CRITICAL CARE TRANSPORT?
Yes
No |
ADDITIONAL INFORMATION |
Person who will accompany patient to UAB: |
| First Name : |
| Last Name : |
| Telephone : |
| Relation to Patient : |
Drug or Food Allergies:
Has the patient ever been hospitalized in the US?
Yes
No
If yes, list U.S. hospitals with dates and reasons of hospitalization:
Will an interpreter be needed to accompany patient during this medical visit?
Yes
No
How did you first hear of the UAB Medical Center?
Physician
Former Patient/Friend
Received Training at UAB
Medical Publications
Newspaper/News
Latin American Representative
Medical Conference
Magazine
Other (please, explain)
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