Physician Medical Stability Form - Choose Life A&V

CHOOSE LIFE A&V REGENERATIVE CLINIC

International Medical Intake Department, Canada

MEDICAL SUMMARY & CLINICAL STABILITY REPORT

To be completed by the attending physician. Must cover at least the last 6 months of clinical history.

1. PATIENT DETAILS

Patient Full Name: _________________________________________
Date of Birth (DD/MM/YYYY): ____ / ____ / ___________
Passport Number: _________________________________________

2. PRIMARY & CONCURRENT DIAGNOSES (Active over the last 6 months)

Primary Fertility Diagnosis: __________________________________________________
Chronic Pre-existing Conditions (e.g., Diabetes, Asthma, Epilepsy, Cardiac, Allergies):
____________________________________________________________________________
____________________________________________________________________________

3. CLINICAL STABILITY CONFIRMATION (Mandatory for Canadian Medical Intake)

The patient’s chronic condition(s) has/have been stable for the past 6 months:

  • [ ] YES, completely stable.
  • [ ] NO, there have been recent exacerbations, hospitalizations, or acute changes.

Has the patient required emergency hospitalization or intensive care in the last 6 months?

  • [ ] NO.
  • [ ] YES (Please specify date and cause): ______________________________________

4. CURRENT MEDICATION PROTOCOL (Last 6 Months Log)

Please list all prescription medications, inhalers, or treatments with their international chemical names (generic names) and precise dosages.

  1. Generic Name: _____________________ Dosage: _________ Frequency: _________
  2. Generic Name: _____________________ Dosage: _________ Frequency: _________
  3. Generic Name: _____________________ Dosage: _________ Frequency: _________
  4. Generic Name: _____________________ Dosage: _________ Frequency: _________

Have there been any alterations, dosage increases, or medication changes in the last 6 months?

  • [ ] NO changes. Medications have been identical for 180+ days.
  • [ ] YES (Please specify changes): ___________________________________________

5. RECENT DIAGNOSTIC LABS (Attached copies must be from the last 3–6 months)

Please confirm attachments:

  • [ ] Endocrinology: HbA1c (for diabetic patients) - Result: _______ %  Date: ________
  • [ ] Cardiology: ECG / EchoCG (for cardiac patients) - Date: ________
  • [ ] Respirology: Spirometry / Asthma control log - Date: ________
  • [ ] Pelvic / Reproductive Ultrasound report - Date: ________

6. PHYSICIAN SIGNATURE & CLINIC STAMP

Physician Full Name: _________________________________________
Medical License / Registration Number: ___________________________
Specialty: _________________________________________________
Clinic/Hospital Name: ________________________________________
Country/City: ______________________________________________
Phone Number: ____________________________________________
Physician Signature: _______________________ Date: ____ / ____ / ___________

[ PLACE OFFICIAL CLINICAL ROUND STAMP HERE ]