Which Medical Records to Send for a Remote Assessment

What does a doctor abroad need from you to give a meaningful opinion before you travel? More than most people send. A two line message and a phone photo of a scan report leads to a generic answer, and sometimes to a plan that has to be changed once you arrive.

A good remote assessment depends on complete, recent and readable information. The list below covers what is generally useful, then what specific specialties tend to ask for. Remember that a remote review is preliminary. It can tell you whether a trip is worthwhile, but it cannot replace an examination.

Key points

• Send a one page health summary first: diagnoses, operations, medicines with doses, allergies, smoking, height and weight.
• For imaging, the original digital files in DICOM format are far more useful than the written report alone.
• Most blood tests and ECGs are considered current for roughly 3 to 6 months if your health has not changed.
• Hiding a condition does not improve your chances. It shifts the discovery to the day of surgery or to the recovery period.
• Share records through a secure channel and send only what is relevant.

The core summary everyone should send

Write this yourself or ask your family doctor for a printed summary. Accuracy matters more than style. Include exact medicine names and doses, since brand names differ between countries, and include supplements and recreational substances. Anaesthetists need this information and are not there to judge.

• Age, height, current weight and any recent large weight change
• Current and past medical conditions, with approximate dates
• Previous operations and any problems with anaesthesia, bleeding or healing
• All medicines and supplements, with doses
• Allergies, including latex, antibiotics, plasters and local anaesthetics
• Smoking, vaping, nicotine replacement and alcohol use
• Pregnancy, breastfeeding or plans for pregnancy
• Personal or family history of blood clots or bleeding problems

Test results and how recent they should be

If you have had blood tests in the last few months, send them. Common requests before surgery include a full blood count, kidney and liver function, blood sugar or HbA1c, clotting tests and sometimes thyroid function. People over a certain age or with heart or lung conditions may be asked for an ECG, an echocardiogram or a chest X-ray, and sometimes a letter from their cardiologist or other specialist.

As a rule of thumb, results from the last 3 to 6 months are usually accepted for planning if nothing has changed. The hospital will typically repeat key tests on arrival. Doing tests at home early has one big advantage: an abnormal result can be dealt with before you have paid for flights.

Imaging: send the files, not only the report

Radiology reports are summaries. Surgeons want to see the images. Ask the imaging centre for a disc, USB stick or download link containing the DICOM files, which is the standard format that any hospital viewer can open. Photographs of films held up to a window, or screenshots of one slice, are rarely adequate.

Large studies do not fit in email. Use the secure upload link offered by the provider or a password protected cloud folder. Include the date and the type of each study in the file or folder name.

What different specialties tend to ask for

Requests vary with the treatment. These are typical examples, and the team may ask for more once they have seen your first set of records.

• Cosmetic surgery: Standardised photographs: neutral background, even light, no filters, front, both obliques and both profiles. For breast surgery in women over about 40, or with a family history, recent breast imaging.
• Hair transplant: Photographs of the hairline, top, crown and donor area with dry hair, plus details of family pattern, medicines tried and any scalp condition.
• Dental treatment: A panoramic X-ray from the last 6 to 12 months, and a cone beam CT scan if implants are planned. Photographs of your smile and bite.
• Bariatric surgery: Weight history, previous attempts at weight loss, related conditions such as diabetes or sleep apnoea, endoscopy results if available.
• Orthopaedics: X-rays taken standing where relevant, MRI files, and notes on previous injections or physiotherapy.
• Eye surgery: Your glasses or contact lens prescription over the last 2 years, corneal topography if you have it, and a note of any dry eye or eye disease.
• Cancer or complex medical cases: Pathology reports, staging scans, operation notes, treatment summaries and, if possible, the pathology slides or blocks for review.

Language, format and organisation

Records in English are widely accepted. Documents in other languages may need translation, and for complex cases a professional medical translation is safer than an automatic one, particularly for pathology and operation notes. Send scanned documents as PDF files, not as dozens of separate phone photographs.

Put everything in date order and add a short cover note that states what you want to know. A clear question gets a clear answer: for example, am I a candidate for this procedure, what alternatives are there, and what further tests do you need?

Privacy and sharing records safely

Medical records are sensitive personal data. Messaging apps are convenient and widely used in medical travel, but they are not designed as medical record systems. Where you have the choice, use a secure portal or an encrypted link. Ask who will see your records, whether they are shared with several hospitals, and how long they are kept.

Send what is relevant and no more. You do not need to send identity documents or payment card details with medical files. Under European style data protection law you have the right to obtain copies of your own records from your doctors at home, usually without charge.

What a remote assessment can and cannot do

From good records a surgeon can usually say whether you are a plausible candidate, which technique is likely, what stay is needed and what would rule you out. They cannot feel tissue quality, measure skin laxity, test joint stability or pick up the subtle signs found on examination. Expect the final plan to be confirmed or adjusted at the in-person consultation, and keep open the option of not proceeding.

When to get medical help

Do not leave out conditions, medicines or past complications in the hope of being accepted. Undeclared heart disease, clotting history, diabetes, blood thinners, eating disorders or psychiatric treatment can lead to serious harm under anaesthesia or during recovery. If a provider accepts you for major surgery without asking for any records or tests, treat that as a warning about the provider. Ask your own doctor for advice if your tests at home show anything abnormal.

This guide is general information and does not replace advice from the doctor treating you. If you would like a specialist to look at your own case, send your reports and photographs: a Clinic-Y coordinator replies within 24 hours, and the case review is free.

Frequently Asked Questions