Special Medical Services Inquiry Thank you for your interest in Special Medical Services from Hospitals for Humanity. All fields in the application are required. Basic information First name Last name Email Phone number Street address Street address continued City State/Province Zip/Postal code Country Gender Female Male Age Medical history What symptoms do you currently have or have had in the past? (If your symptoms include pain, please describe how severe the pain is and how long it has lasted.) When did you start experiencing the symptoms? Have you been diagnosed? No Yes When were you diagnosed? If you haven't been diagnosed, please type "N/A." What were the results of diagnosis? (Please be as detailed and thorough as possible.) If you haven't been diagnosed, please type "N/A." What kind of treatment have you received so far? If you haven't received any treatment, please type "N/A." Please list your current medications. If you are not currently on any medications, please type "N/A." Please check any of the following that apply to you. Smoke cigarettes Drink alcohol Have a drug addiction None of these Do you think you are stressed or depressed? Please check as many of the boxes below that apply to you. Stressed Depressed Neither
