PHYSICAL/MEDICAL QUESTIONNAIRE – Shaw Medical Travel Consultants

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Shaw Medical Travel Consultants

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PHYSICAL/MEDICAL QUESTIONNAIRE

MEDICAL (Check all that apply)

Migraines

Allergies

Heart failure

Diabetes

Chronic pain

Depression

Anxiety

HIV

Hepatitis C

Kidney failure/Dialysis

Heart disease

Lung condition

Cancer

Neurological disease

Blood disease

Other infectious disease

Other psychiatric condition

Check conditions that you have frequently (multiple times a month)

Headaches

Dizziness

Lightheadedness

Nausea

Vomiting

Double vision

Blurred vision

Chest pain

Rapid heartbeats

Skipped heartbeats

Arm numbness

Neck pain

Radiating pains

Back pain

Low back pain

Numbness

Tingling

Radiating pains from back down leg

Medications

PERSONAL GOALS (Check all that apply)

Embrace empathy

Develop self-confidence, goal setting, perseverance

Learn to actively listen - pay attention show others you value their opinions

Face fear head on - learn to be comfortable with ambiguity and uncertainty

Improve your body language

Get along with yourself - learn to appreciate and accept your skills ,experience philosophes aspiration's and limitations

Get along with others

Stop procrastinating

Wake up early

Become more proactive

Healthcare beyond borders

Home
About us
Programs
Blog
Videos
Newsletters
Q&A
Contact
Our sponsors
ShawOpCo – 501(c)(3)
- Board Members

CONTACT US

SUBSCRIBE TO SHAW MEDICAL TRAVEL CONSULTANTS

info@shawmedco.org

Legal advisor: Ment Law Group, PC.

Follow us at @shaw_medculcomp