Ouverture de dossier - Mon Séjour Médical

Detailed health questionnaire –

My Medical Stay

Thank you for your interest!

This questionnaire helps us better understand your medical needs, medical history, and expectations. It is required to validate your request and offer you a suitable care plan. Your answers are confidential and will be handled only by our medical team.

Personal information

First name

Name

E-mail

Telephone (optional)

Gender

City and country of residence

I have read and agree to the Privacy Policy of Mon Séjour Médical Inc., including the collection, use, disclosure, transfer (including outside Quebec and/or Canada), and retention of my personal information, including health information, in accordance with applicable laws (Act 25 – Quebec, PIPEDA – Canada). I understand that my information may be shared with healthcare professionals and/or institutions located abroad for the purpose of analysis.

Your current state of health

Main reason for your request: (Check the option(s) that apply to your situation)

Other (please specify):

Do you have any current medical diagnoses?

Yes

No

If yes, please specify:

Are you currently taking any medication?

Yes

No

If yes, please specify:

Do you have any allergies?

Yes

No

If yes, please specify:

Have you undergone any surgical procedures?

Yes

No

If so, which ones and when?

Medical history

Check the box if you have had or currently have: (Note: The following appears to be a separate, unrelated section:)

If yes, please specify:

Do you smoke ?

Yes

No

Do you drink alcohol?

Yes

No

Do you drink alcohol?

Yes

No

Do you regularly engage in physical activity?

Yes

No

Are you on a specific diet?

Yes

No

If yes, please specify:

Up-to-date vaccinations/immunizations:

Yes

No

If not, please specify which ones:

Preferences or restrictions regarding treatments or medications:

Yes

No

If not, please specify which ones:

Recent pain and symptoms

Do you currently have:

Chronic pain

Excessive fatigue

Fever

Other symptoms:

Documents (optional)

You can attach any relevant medical documents (results, reports, prescriptions, etc.):

Download

Your goals and preferences

When would you like to plan your departure for medical treatment?

Desired length of stay?

Flexible

3 to 14 days

Other, please specify:

Would you like to be accompanied during your stay?

Yes

No

If so, how many people?

Specific needs to be taken into account:

Independent Package (flexible duration) - You manage transport and accommodation, we organize the search for specialists and your medical appointments.

Health Check Package (basic, standard, advanced – duration 3 to 14 days) - Everything is included: flight, accommodation, care, accompaniment.

Customized Care Package / Intervention / Other (duration varies according to your needs) - Consultation, intervention, specialized care. Everything is included: flight, accommodation, care, support.

Desired destination

Puerto Plata

Punta Cana

Cartagena

Medellin

Electronic Communications Consent (Email/SMS) I agree to receive electronic communications (emails and/or SMS) from Mon Séjour Médical Inc. regarding my file, coordination steps, appointments, confirmations, and documents. I may withdraw my consent at any time.

Consent & Medical Authorizations I authorize Mon Séjour Médical Inc. to collect, use, and disclose my personal and health information , as well as the documents submitted, to the healthcare professionals and institutions involved in my care (including those abroad), solely for the purpose of analyzing feasibility, obtaining an estimate, and planning and coordinating my care. I understand that this information may be disclosed and processed outside of Quebec and/or Canada.