Medical History Questionnaire
All questions contained in this questionnaire are strictly confidential and will become part of your medical record
PERSONAL INFORMATION
Name Surname
*
Name
Surname
Date of Birth
*
.
Gün
.
Ay
Yıl
2 digit day, 2 digit month, 4 digit year
Date
Weight
*
Height
*
Gender
*
Woman
Man
CONTACT INFORMATION
E-Mail
*
example@example.com
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Adress
*
Address Line 1
Address Line 2
Country
Province / State
Post code
EMERGENCY CONTACT
Name Surname
*
Name
Surname
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Relationship
*
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MEDICAL HISTORY
Do you have, or have had any of the following medical conditions? Please select ‘yes’ if any of these conditions apply to you.
Heart Disease
*
Yes
No
Diabetes
*
Yes
No
High Blood Pressure
*
Yes
No
Thyroid Disease
*
Yes
No
Chest Pain
*
Yes
No
Heart Murmur
*
Yes
No
Shortness of Breath
*
Yes
No
Asthma
*
Yes
No
Blood in Phlegm
*
Yes
No
Difficulty with Anesthetic
*
Yes
No
Arthritis
*
Yes
No
Kidney Stones
*
Yes
No
Blood in Urine
*
Yes
No
Blood Transfusion
*
Yes
No
Anemia
*
Yes
No
Bleeding Disorder
*
Yes
No
Deep Vein Thrombosis i.e. Blood Clots
*
Yes
No
HIV
*
Yes
No
Hepatitis
*
Yes
No
AIDS
*
Yes
No
Herpes
*
Yes
No
Poor Scarring e.g. Keloids
*
Yes
No
Stomach Ulcers
*
Yes
No
Urinary Tract Infection
*
Yes
No
Cancer
*
Yes
No
Hernia Repair
*
Yes
No
Nervous System Disorder
*
Yes
No
Mental Health Disorder
*
Yes
No
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MEDICAL HISTORY
Do you have, or have had any of the following medical conditions? Please select ‘yes’ if any of these conditions apply to you.
Have you had any previous surgeries?
*
Yes
No
If your answer is "Yes", please tick one of the choices below.
*
Yes
No
If your answer is "Yes", please fill in the fields below.
Please state your requested Treatment
*
Please list all medications you are currently using including prescription and over- the-counter medications, herbal remedies, vitamin supplements, inhalers, blood thinners.
*
Please list any other medical conditions you’d like your surgeon to be aware of
*
Please list all the medications you are allergic to, if any
*
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WOMEN ONLY
Are you sexually active?
Yes
No
If applicable, what birth control method do you use? i.e. contraceptive pill
Have you had any births?
Yes
No
If your answer is "Yes", please fill in the fields below.
Have you had any abortions?
Yes
No
If your answer is "Yes", please fill in the fields below.
Have you had any miscarriages?
Yes
No
If your answer is "Yes", please fill in the fields below.
Have you breastfed in the last 12 months?
Yes
No
If your answer is "Yes", please fill in the fields below.
When was your last menstrual period?
*
Have you recently checked your breasts for lumps?
*
Yes
No
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HEALTH HABITS
Do you drink alcohol?
*
Yes
No
If your answer is "Yes", how much do you drink per week?
Do you smoke?
*
Yes
No
If your answer is "Yes", how many cigarettes do you smoke per day?
Do you use recreational or street drugs?
*
Yes
No
If your answer is "Yes", what do you use?
Please verify that you are human
*
Signature
*
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SUBMIT MEDICAL HISTORY
SUBMIT MEDICAL HISTORY
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