Executive Health Assessment Summary

Application Form Continued

VIP docs is a company created by the Iasis Corporation that was created to deliver an alternate supply of health care services to the public in an ever-changing medical environment. One of our present services that we offer is a corporate medical assessment that can be tailor-made to your requests or needs. Presently we offer this service through physicians originating from the United States. As this service is considered third party, it is not considered an OHIP or insurance benefit at this time. The services that we offer at this time include:

General medical examination and assessment
Electrocardiogram assessment
Serological examinations
Gastroenterology examination and assessment with or without endoscopy
Neurological examination and assessment
Cardiovascular examination and assessment including stress testing, echo cardiography
Pulmonary examination and assessment
Radiological examinations and reporting for routine screening including chest X-ray, mammography, CT scans, MRI scans, bone density scans and more
Psychological examination and assessment
Other consultations are available on special request

This Confidential* Executive Summary application form is essential for the physician to understand your unique medical history and current needs. Only those who fully complete this form can be considered for consultation. An assessment plan and fee structure will be forwarded to you based on the information provided.

Patient First Name

Patient Last Name

Corporation

Are you pregnant?
Are you nursing?

Check off any of the medications you take:

Coumadin or Warfarin
Heparin
Asperin
Non-steroidal-anti-inflammatories (NSAIDS) e.g.. Naprosyn, Vioxx, Celebrex
Heart Medication
Seizure Medication
Blood Pressure Medication
Cancer Medication or Chemotherapy

List the prescription medication that your doctor(s) have prescribed not covered above:

List the over-the-counter (OTC) medication that you take regularly:

Do you suffer from any of the following PAIN conditions?:

Osteoarthritis
Rheumatoid Arthritis
Any other Arthritis
Fibromyalgia
Myofascial Pain Syndrome
Tendonitis
Bursitis
Back pain
Neck Pain
Degenerative Spinal Disease
Herniated Disk
Carpal Tunnel Syndrome
Patellofemoral Syndrome
Temporomandibular Joint Disease or TMJ
Rotator Cuff Injury
Repetitive Strain Injury

Have you ever suffered from any of the following MEDICAL conditions?

Heart Disease
High Blood Pressure or Hypertension
Migraine Headache
Arthritis (any kind)
Cancer
Anaemia
Asthma
Emphysema
Lung disease
Male or Female Fertility Problems
Chronic Pain (any kind)
Depression
Suicidal
Hallucinations or Delusions
Peptic Ulcer Disease
Irritable Bowel Syndrome
Inflammatory Bowel Disease (Crohn's Disease, Colitis)
Kidney Disease or Failure
Diabetes
Liver Disease
Hepatitis (any kind)
Drug or Alcohol Addiction
Chronic Skin Disease or Open Sores
Chronic Penile or Vaginal Discharge
Chronic Infections (any kind)
Glaucoma or other Eye Disease
Bleeding Disorder
Chronic Nose Bleeds, Rectal Bleeding, Blood in Urine

List all of your allergies:

List all of your operations or other reasons for hospital visits:

List any special areas of concern you would like to have investigated:

Anything else you want the doctor to know?

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Last updated July 21, 2008