Appendix C: Sample Medical History Form

Fill this out in English, have it translated professionally, and bring multiple copies to give to every new doctor.

PATIENT MEDICAL PASSPORT

Personal Information

Name: _________________________

Date of Birth: _______

Passport #: _____________________

Nationality: ____________________

Blood Type: ______

Primary Medical Problem & Reason for This Visit

---

---

Current Medications & Supplements

1. _________________ Dose: _______ How Often: _______

2. _________________ Dose: _______ How Often: _______