Questionnaire/Reservations

No Pain

____________________________________________________

Pain as bad as it can be

BioMagnetic Medical Institute

for Arthritis & Sports Injuries

Patient's Pre-Admission Questionnaire

Prior to acceptance a prospective patient must complete and submit the following Questionnaire to The Institute. It is also important to send x-rays, MRI and all medical diagnosis and reports for review by the BioMag Medical Review Board.

Date:

Name:

Address:

Age: Weight: Height: Waist size:

Occupation:

Hobbies:

Telephone home: Work:

E-Mail address:

Please indicate all types of pain & location:

Area of pain: Type of Pain (deep, superficial, radiating, burning, stabbing, numb, tingling and/or aching):

Is pain constant or intermittent?

As a result of your condition, mark your present level of pain on the scale below:

Indicate you level of pain while doing the following activities:	Never	Sometimes	Most of the Time	Always
a. When active
b. Inactive
c. At night
d. Inflammation (swelling)
e. Tenderness
f. Specify other
For lower extremities only:
a. Standing for more than 15 minutes
b. Walking more than one block
c. Climbing up or down flight of stairs
d. Getting up from a chair (or toilet)
e. Turning in bed at night
f. Kneeling, reaching into a lower cabinet
g. Specify other
Cervical Spine:
a. Getting in and out of bed
b. Getting in and out of chair
c. Specify other
Upper Extremities:
a. Combing your hair
b. Brushing your teeth
c. Eating
d. Writing
e. Dressing
f. Specify other

Pain increase with

Pain decrease with

2. Prior treatments received & list medications currently taken:

3. Surgery:

Had: Planned:

4. Medical history & indicate how long have you suffered from your condition:

Have you suffered any other illness: Yes: No:

If answered yes, please list:

Describe your family history of chronic diseases:

5. Nutritional Assessment

What is your cultural background? Do you have dietary restrictions?

List any known food allergies:

Have you ever been on a diet? If so, please describe:

Average number of meals taken per day? At what times do you eat each day?

Please list all food supplements (vitamins, minerals, etc.) which you take:

6. General Health Condition:

Pacemaker

Pregnancy

Cancer

Other:

Send your most recent medical report, x-rays, MRI and/or CAT scan for review by the BioMag Medical Review Board (required prior to admission).

BioMag� Reservation Request and Payment Order

Date:

Your BioMag Appointment No. Confirmation No.

Name:

Address:

Telephone Home: Fax:

Office or Work: E-Mail:

Passengers' Name(s):
1. 2.
3. 4.

Others:

Date & ETA: Airline & Flight No.
(Estimated time of arrival)

Date & ETD: Airline & Flight No.
(Estimated time of departure)

GRUPO TACA Airlines or COPA Airlines Special Services:

Special Meal:

Wheel chair: Yes: No:

Premier Coach Class: Executive Class:

Caesar Park Panama Hotel Services:

Type of Room: SGL DBL Jr. Suite Children

No Smoking Room: Yes: No: Wheel chair accommodation: Yes: No:

Special Requests:

Other Medical Services Required:

Other Services Required:

Total Payment Due: 50% due when making reservation & balance upon arrival.

Form of Payment:

Credit Card: Card Number:

Bank transfer or check:

Comments:

BioMag�

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