Patient Data and Medical History Form

Patient Data & Medical History Basic

TAJ Card – Hungarian National Health Insurance Information. It will NOT be accepted for payment.

I have my TAJ Card Number and I can upload a Copy of my TAJ Card

I do not have a TAJ card, I do not have this type of government insurance

I do not know my TAJ card number or I cannot upload a Copy of my TAJ Card now

TAJ Card Number – 9 digits.

Upload a Copy of your TAJ Card!

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Photo Identification Document, preferably Passport, alternatively Local Residence Permit, Country’s National Identification Card or Driver License Serial Number, that you have a copy and can upload.

Upload a Copy of the Data Page of your Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Patient’s Family Name (Surname)

Patient’s Given Name

Birth Name. Is your Name now the same that you had on your Birth Certificate?

Yes, my name is the same that I had at Birth.

No, I had a name change since Birth due to marriage, voluntarily or for other reasons.

Birth Name (Family)

Birth Name (Given)

Mother’s Maiden Last Name

Mother’s Maiden First Name

Gender – in Hungary only Male or Female Genders are officially recognized.

Male

Female

Place of Birth – Country

Place of Birth – Town, City

Date of Birth; Year.Month.Day

Permanent (Home) Address

Street Name and Number

Supplemental Information about Home Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Additional Address. Would you like to provide any other, such as Billing or Temporary address?

Yes

Additional Address. Temporary stay, Hotel or other Accomodation. Billing Address if different from Home Address.

Street Name and Number

Supplemental Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Additional Address

Email Address that you want to use for Urgent and Confidential Communication.

Confirm the Email Address that you want to use for Urgent and Confidential Communication.

Mobile Phone number with Country Code

Local Phone/Mobile Number

The Reason for Consultation, Doctor Visit, Service Request..

File Upload – Optional. You may attach additional document copies, such as medical reports, lab or imaging testing, prescriptions, immunization cards.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Medical Information. Have you had any Prior Illnesses, Hospitalizations, Surgeries?

Yes

Your Medical Diseases, Conditions from the past.

Asthma, Allergy

Cancer, Tumors

Diabetes

Deep Vein Thrombosis, Emboli

Heart attacks, Heart valve disease, Arrythmias

High Blood Pressure

Stroke, Paralysis

Thyroid Disease

Other (describe in next window)

Past Medical History. Chronic Diseases, Hospitalizations and Surgeries.

Current and Regular Medications and Treatments

I do not take any medications now and I do not have any regular prescribed treatments.

I take medications now or occasionally

Medications and Treatments. You may choose any or all of the listed.

I am being treated only now with some medications, but I do not take them regularly.

I take certain medications regularly (for a chronic condition or disease).

I only occasionally, but not daily take some medications (for example as needed for headache, backpain).

Exact Name and Dosage of Current but not Regular Drugs and other Treatments.

Exact Name and Dosage of Regular (Daily) Drugs and other Treatments

Exact Name and Dosage of Drugs and Treatments you may use occasionally

Hormonal Contraception (Pregnancy Prevention)

Yes, I use hormonal contraceptive, tablets or other form (e.g. depo injection, hormone releasing IUD).

No, I do not use hormonal contraceptive medications, or hormone releasing IUD.

Exact Form, Name and Dosage of Hormonal Contraception

Are you possibly pregnant (expecting a child) now?

Yes

First Day of Your Last Menstrual Period. Estimate the date, if you do not recall exactly. YYYY.mm.dd.

Allergies and Adverse Drug Reactions

No known drug allergies or adverse reactions.

I had allergies or adverse reactions to drugs.

Specify what exactly happened when you took the medication in question causing Allergy (e.g. skin rash, wheels, breathing problem, shock, anaphylaxis).

Your Weight in Kilograms

Your Height in Centimeters

Body Mass Index ( Automatically Calculated)

Smoking History. Have you smoked more than 50 cigarettes / cigars in your life? Did you chew tobacco?

Yes

How much have you smoked in your life? How many boxes, for how many years?

Do you drink alcohol? Have you consumed alcohol regularly in the past?

Yes, more than 3 drinks a day

Yes, 1-2 drinks a day

Yes, less than 1 drink a day

Yes, but only very occasionally

No, I do not drink alcohol at all

What kind of alcoholic beverages, how much, how often and for how many years?

Family History. Any significant medical diseases, conditions in your first and second degree blood relatives?

Yes

I do not know, I am not sure

Family History Details.

Asthma, Allergy

Cancer, Tumors

Diabetes

Heart attacks, Stroke

High Blood Pressure

Other

Family History details of (other) medical conditions

Other Important Information you would like us to know. Optional field.

Additional File Upload – Optional

Choose File (pdf, jpeg, jpg, png, bmp, gif)

As I proceed with the Submission, I confirm that I read and agree to the content of the Service Provider’s website, including but not limited to Prices and Fees, General Information and Policy as well as the Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when I was not available for the requested and scheduled visits or services, according to the Terms and Conditions.

Signature – Type your full name here as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.