Medical History Form – Revitalize In Turkey

PATIENT DETAILS

MEDICAL INFORMATION (DO YOU HAVE OR HAVE YOU HAD)

PAST SURGERIES

WOMEN ONLY

DO YOU HAVE OR HAVE YOU HAD SLEEP APNEA ? PLEASE CONSIDER THE FOLLOWING SYMPTOMS OF SLEEP APNEA

DO YOU HAVE OR HAVE YOU HAD DEEP VEIN THROMBOSIS OR PULMONARY EMBOLUS ? ANY PAST OR PRESENT HISTORY OF ANY OF THE FOLLOWING

Ayse Mayda Sok, No: 15c Kucukyali, Konak, Izmir.

UK Patient Coordinator (Jackie Bonham)
0 (788) 436 15 46

Whatsapp Support Line:
00 90 532 425 73 88

PATIENT DETAILS

Name Surname

Date of Birth

Weight And Height

Address

Phone Home

Phone Work

Mobile

E-Mail

MEDICAL INFORMATION (DO YOU HAVE OR HAVE YOU HAD)

AIDS or HIV+

Anemia

Arthritis

Asthma

Back Problems

Bladder Infection

Bleeding Tendency

Blood Clots

Bronchitis

Cancer

Colitis

Congenital Heart

Diabetes

Epilepsy

Fainting Spells

Goiter

Hay Fever

Hearth Attack

Hepatitis

High Blood Pressure

Kidney Disease

Leukemia

Liver Disease

Migraine

Nervous Breakdown

Pain in the Chest

Palpitations

Pneumonia

Rheumatic Heart

Shortness of Breath

Stomach Ulcers

Stroke

Thyroid Disease

Tonsilitis

Tuberculosis

Other serious illness that you have had

Do you regularly smoke? (If yes, how much?)

Do you regulary drink 6 or more cups of coffee per day?

Do you regularly drink alcohol or beer? (If yes, how much?)

Have you recently had chest x-ray? (If yes, when?)

Any metal implants/devices (If yes, list?)

Do you wear spectacles?

Do you wear contact lenses?

Do you wear dentures?

Have you recently had a cold or flu? (If yes, when?)

Please list any medications (presription or over-the-counter) that you have taken within the last month

Are you presently taking any medications (If yes please list them)

Do you know of any blood relative who has or had any chronic or congenital disease (If yes please give all details)

Do you have any allergy? (If yes please give all details)

PAST SURGERIES

Date

Type

Hospital

Have you had complications or bad reactions to anesthesia ? (List)

Have you ever had a blood transfusion ? (If yes, when?)

Have you had a significant weight change in the last year ? (If yes, please give details)

Do you have frequently bleeding gums ?

Have you ever bled excessively from a tooth extraction ?

Do you bleed excessively from a laceration ?

Have you ever had a blood transfusion ? (If yes, when?)

WOMEN ONLY

Is there any chance you may be pregnant ?

Number of Pregnancies

Number of Children

Are you still having regular menstrual periods ? (If yes, date of last menstrual period)

Date of last mammogram

Result

DO YOU HAVE OR HAVE YOU HAD SLEEP APNEA ? PLEASE CONSIDER THE FOLLOWING SYMPTOMS OF SLEEP APNEA

I am frequently tired upon waking and throughout the day

I have trouble staying asleep at night