Admissions Form

Sanoviv Medical History and Application for Admission

Thank you for taking the time to fill out this form. This will allow us to address your concerns and explain what Sanoviv can do for you. Please fill it out as completely as you can. After submitting this form, please contact your admissions coordinator to schedule the date and time of your call.

* First Name


Middle name


Last Name


Gender

Date of birth

 dd   yyyy: 

Address


City


Country

Zip/ Postal Code


Occupation (Please write up to four words).


Preferred phone number to receive Sanoviv´s call, please include the country code, area code and phone number.

Home Phone
Cell
Skype account

Email Address


Religion


Marital Status

Person to contact in case of emergency


Phone number of contact person


Relationship with contact person


What is your primary language?


Do you require translation in order to communicate in English?

How did you hear about Sanoviv?

Please summarize your current health status.


What is the diagnosis that you have received? (Please include date of the diagnosis). If you do not have a diagnosis, what are your main health issues?


What do you want to achieve at Sanoviv?


In your opinion, What might have contributed or caused some of your main health complaints? Did anything significant happened in your life close to the time of onset?


Describe briefly the chronological evolution of your symptoms or/and diagnosis. Please include dates if possible.


What treatments have you done in the past and which ones are you currently receiving? Please specify dates if possible.


How physically independent are you?

Have you had any medical tests recently? If yes, please list the name of the test, date, and result.


What do your doctors say about your condition?


Do you have any known food allergies (that will cause an anaphylactic reaction)

Do you have any known food sensitivities (those that may cause mild reactions)

Please note any food allergies or sensitivities for your companion, if applicable


Have you ever been hospitalized for mental/emotional problems?

Do you have any sensitivities or allergies to medication?

Have you had any surgery? if yes, elaborate.


Have you ever been diagnosed with an infectious disease?

In case of cancer, what types of chemotherapy or other treatments have you had?


Are you taking any medication or nutritional supplements? Please describe.


Are you taking any amphetamines (Adderall), Benzo (Valium, Xanax), or any antidepressant medications?

 
 

Do you smoke or vape, or use tobacco, cannabis, or other addictive substances?

Are you pregnant, or is there a possibility you may become pregnant before you come to Sanoviv?

 No       
Yes