Date that form is filled out:

GENERAL PRE-CONSULT yyyy/mm/dd

Revision Dates (Doctors only)

FORM
yyyy/mm/dd

Thank you very much for contacting us. We realize that going overseas for medical surgeries can be both adventurous and
affordable, and we are very interested in helping you find the best quality of care at a reasonable price.

One of our goals is to make sure you arrive safely for your medical procedure, that you will be eligible for the surgery you travel to
receive, and that you will get a reasonable outcome.

We have traveled to acclaimed and accredited hospitals and clinics throughout the globe and have met with the surgeons we have
recommended to make sure you will get the best possible treatment. Our criteria to determine who is best qualified to assist you
include reviewing the surgeon's background, making sure they speak English, have a "people personality", and that the hospitals
are clean and comfortable. We also make sure that the hotels are comfortable for a post operative client. Your honest answers will
help us ensure that your healthcare objective will be met. All your responses are kept confidential and are reviewed only by
medical professionals.

In order to make sure you will not put yourself in potential risk or experience any problems during your medical procedure, we have
assembled a comprehensive Pre-Consultation Form designed to help identify any potential problems. Our report is not based on
personal opinions; they come from data gathered from the following organizations:

• American Society of Anesthesiologists (ASA)

• The Center For Disease Control (CDC)
• the Aerospace Medical Association (AsMA)
• Joint Commission of Accreditation for Health Organizations (JCAHO)
• Royal College of Surgeons (UK)

Only a PlanetHospital Medical Professional and the appropriate overseas surgeons will review this form. Any medical records you
send will be kept confidentially and encrypted and accessible only by a Medical professional and the overseas surgeons.

Upon completion of this pre-consult form hit the SEND Button at the end of the form and you will be alerted to some security
procedures designed to keep your records confidential.

If you choose to print this form and send it back as a fax or mailed document, please hit the (PRINT) button now otherwise hit
NEXT to begin.

*information that you may need to know *

BEFORE YOU START! This form should take between 15-20 minutes to fill out. If you have your x-rays or photos of the body part
to be modified, you will be given the opportunity to upload them at the end of the form but it might be worthwhile to have these
available before you get started. If for any reason you cannot fill out this form in one sitting, your data will be saved and you can
log back in and complete it at your leisure. If you have any trouble with this for please call us immediately and ask for Technical
Support. If you wish to see how your data is kept confidential please fill click on this link (confidentiality and HIPAA policy).

Solomon, after this part, we should have the name they entered appear as well as their email address and then ask for a password so that they can
save and retrieve their work. Also I have color-coded each section for you.
 GENERAL HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record. All * marked fields are mandatory

TAB NAME: GENERAL

QUESTIONS
Date Of
Telephone: 3333333333
Name*: Pavel Shkurikhin Birth:* 10191979
Gender: Male
yyyyy/mm/dd
Procedure Requested * fghfgh Email address:*
Height:* ft in
Weight:* lbs or kgs
or cm
Marital
Married
status:
Date of last physical exam:
Current doctor: gfhfghgfh Telephone:
yyyy/mm/dd 4/22/2009
Do we have permission to contact Yes

PERSONAL HEALTH HISTORY (PART 1)*

Childhood illness:  Measles  Mumps  Rubella  Chickenpox  Rheumatic Fever  Polio

Immunizations and Tetanus 0 Pneumonia

dates: (enter the year
immunization received if Hepatitis Chickenpox
known) Influenza MMR Measles, Mumps, Rubella

Do you have/ever had any of the following:* select all that apply
AIDS/HIV + Anemia Arthritis Auto-Immune Asthma

Autoimmune Back Problems Blood Clots Blood Disorders Bleeding Problems

Disorder (LUPUS)

Breathing Problems Cancer Chest Pains Colitis/Crones Depression

Ear Problems Eye Problems Epilepsy Heart Problems Heart Murmur

Hepatitis High Blood Pressure Irregular Heart Beat Kidney Problems Liver Problems

Migraine Headaches Nervous Breakdown Nose/Throat Problems Osteoporosis Pneumonia

Any Psychiatric Rheumatic Fever Shortness of Breath Skin Cancer Sleep Disorders
Conditions
Stomach Problems Stroke Thyroid Problems Tuberculosis Hip Pain

Back Pain Knee Pain Leg Pain Leg and Feet Swelling

Carpel Tunnel Orthopedic Surgery Thyroid Condition

Keloids (difficulty healing Diabetes type 1
or scaring) Diabetes type 2
Do you have/ever had any following symptoms of cardiovascular disease? *select all that apply
Angina (Chest Pain) Coronary Artery High Cholesterol Thrombophlebitis (blood Congestive Heart Failure
times? Disease clots in veins)

Venous Insufficiency Hypertension Heart Attack, How

(varicose veins, many times?
numbness in feet)
Do you have any implants or metal objects in your body?* select all that apply
Plates or screws or Total Hip Total Knee
any other hardware Replacement/Resurfacing Replacement
from an orthopedic
procedure?
Cosmetic Implants
Where:

What made you decide to go overseas for this procedure?

 PERSONAL HEALTH HISTORY (PART 2)*

Please list any previous surgeries*

Year Reason Hospital

Other hospitalizations (including pregnancies if applicable)*

Year Reason Hospital

Have you ever had a blood transfusion?* Yes No

List your prescribed drugs, over-the-counter drugs, AND HERBS such as vitamins and inhalers*

Name the Drug Strength Frequency Taken

Allergies

What you are allergic to: Reaction You Had:

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise* Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet* Are you dieting? Yes No

If yes, are you on a physician prescribed medical diet? Yes No

# of meals you eat in an average day?

Rank salt intake Hi Med Low

 Rank fat intake Hi Med Low

Caffeine*  None Coffee Tea Cola

# of cups/cans per day?

Alcohol* Do you drink alcohol? Yes No

If yes, what kind?

How many drinks per week?

Tobacco* Do you use tobacco? Yes No

Cigarettes – pks./day Chew - #/day Pipe - #/day Cigars - #/day

# of years Or year quit

Drugs Do you currently use recreational or street drugs or have used in the last 5 years? Yes No

Have you ever given yourself street drugs with a needle in the last 5 years? Yes No

Sex Are you sexually active? Yes No

(please note
this question is If yes, are you trying for a pregnancy? Yes No
mandatory for If not trying for a pregnancy list contraceptive or barrier method used:
any
IVF/surrogacy Any discomfort with intercourse? Yes No
related
inquiries)
Any sexually transmitted diseases?
Yes No

FAMILY HEALTH HISTORY

LEAVE BLANK WHAT YOU DO NOT KNOW…
AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS

Children M
Father
F
M
Mother
F
Sibling M M
F F
M M
F F
M Grandmother
F Maternal
M Grandfather
F Maternal
M Grandmother
F Paternal
M Grandfather
F Paternal

MENTAL HEALTH*

Is stress a major problem for you? Yes No

Do you feel depressed? Yes No

Do you panic when stressed? Yes No

Do you have problems with eating or your appetite? Yes No

Do you cry frequently? Yes No

Have you ever attempted suicide? Yes No

Have you ever seriously thought about hurting yourself? Yes No

Do you have trouble sleeping? Yes No

Have you ever been to a counselor? Yes No

 WOMEN ONLY*

Age at onset of menstruation:

Date of last menstruation:

Period every days

Heavy periods, irregularity, spotting, pain, or discharge? Yes No

Number of pregnancies Number of live births

Are you pregnant or breastfeeding? Yes No

Have you had a D&C, hysterectomy, or Cesarean? Yes No

Any urinary tract, bladder, or kidney infections within the last year? Yes No

Any blood in your urine? Yes No

Any problems with control of urination? Yes No

Any hot flashes or sweating at night? Yes No

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Yes No

Experienced any recent breast tenderness, lumps, or nipple discharge? Yes No

Date of last pap and rectal exam?

MEN ONLY

Do you usually get up to urinate during the night? Yes No

If yes, # of times

Do you feel pain or burning with urination? Yes No

Any blood in your urine? Yes No

Do you feel burning discharge from penis? Yes No

Has the force of your urination decreased? Yes No

Have you had any kidney, bladder, or prostate infections within the last 12 months? Yes No

Do you have any problems emptying your bladder completely? Yes No

Any difficulty with erection or ejaculation? Yes No

Any testicle pain or swelling? Yes No

Date of last prostate and rectal exam?

OTHER PROBLEMS

Check if you have, or have had any symptoms in the following areas to a significant degree and briefly explain.

Skin Chest/Heart
Head/Neck Back
Any Recent changes in:
Ears Intestinal Weight
Nose Bladder Energy level
Throat Bowel Ability to sleep
Lungs Circulation Other pain/discomfort:

TRAVEL DATA
When were you thinking of getting this procedure done?
immediately 30-90 days 90 days-6 months 6 months+ Next Year Not sure yet
 How much time can you dedicate to your surgery and recovery?
As much time as needed 30 days 15-20 days Less than two weeks Not sure yet

Can you handle a flight longer than 6 hours Yes No

If NO, would you be able to handle a long fight if there were multiple stops? Yes No

Please list any food dislikes (eg: No spicy foods, vegetarian only, etc)

Do you have a passport (if not, we can arrange one for you) Yes No

Will you be bringing a companion? Yes No

Will your companion require a passport? Yes No

DISCLAIMER
It is important that you never withhold any information about your health issues from us, your Case
Managers, or the doctors or dentists in our network. If there are any health matters not covered in this
questionnaire that you think might be pertinent to your state of health, please recheck the box above and add any
additional information you may have left out.

The statements made in the pre-consult form are true and accurate. I authorize to share this data with various medical
providers within their network. I understand that Planet Hospital is not a medical service provider nor have they provided
me with any medical advice. will only pass my information to doctors. I hold harmless from any errors or omissions I may
have made in this pre-consult form.

Did someone else complete this form out for you? no yes Name: Relationship: