Dr Kim Jin Hong MD PhD Medical History Form
            
*Complete and return this basic medical history to Dr Kim Jin Hong.

<Contact@UroDoc.CO>

** If you prefer security, privacy and confidentiality, compress and encrypt your folder containing all documents and photos (using apps such Archive Utility, Keka, WinZip, Stuffit, WinRAR, or 7-Zip) and send it to us via SendSpace.com and not as an email attachment.

If you opt to use encryption, send us the password by email.

*** The doctor always requests sharply focused, high quality photos shot in good lighting from various angles showing physical problems so he can provide a meaningful free long-distance evaluation.

Many modern web browsers such as Firefox can edit PDF files.

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Name: (as in passport)

Surname (Family Name): (as in passport)

Date of Birth:

Have you sent us photos showing the problems?

Gender:

Weight: (specify kilograms or pounds)

Height: (specify cm or inches)

Your Body Mass Index (BMI):

You diagnosis:

Have you previously had surgery of any type? (if yes, list procedure(s) and date performed)

What Procedures Do You Require?

What Specific Results Do You Expect?

Planned/Proposed Date for Surgery:

Have you made yourself aware of the risks involved in the surgery you want?

Have you made yourself aware of all the possible complications that can occur from the surgery you want?

Questions for the Surgeon:

Your Email Address:

Your Phone Number: (with country code)

Your Current Address:

Nationality:

Preferred language:

Person to Contact in Case of Emergency:

Emergency Contact Person’s Email Address:

Emergency Contact Person’s Phone Number:

Do you have Hepatitis B or Hepatitis C or are you HIV+?

Are you allergic to any food, drug or anything else? (if yes, explain)

Any additional information your surgeon should know but we didn't ask about? (if yes, explain)

