Health Check Form Healt Check Form Please fill in the information below Selection of Surgery / Procudures? * Gastric / Obesity Procudures Aesthetic / Cosmetic Hair Transplant Dentistry General Surgery Orthopedic Surgery Name Surname * Name Surname First First Last Last Email * Phone Number * Section Buttons Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelIsle of ManItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Occupation Emergency Contact Person Name Surname * Emergency Contact Person Phone Number * Medical History Date of Birth * Sex * Male Female Height * Weight * BMI Index * Do you smoke on a daily basis? * Yes No Do you drink alcohol / day? * Yes No Do you have any allergies to medications or food you have? If so, could you please list them below? * Please list any medical conditions / chronic diseases you have ( Heart Disease, Tachycardia, Arrhythmia, Hypertension, Stroke, Kidney Disease, Cancer, Diabetes, Hepatitis, Seizures, Depression, Asthma, High or Low Blood Pressure, Epilepsy, Dizziness or Fainting, Shortness of breath, High Cholesterol, Difficulty Sleeping/Apnea, Anxiety, Headaches or Migraines etc. ) * Have any of your first-degree relatives experienced the following conditions?(Heart Attack, High Cholesterol, High Blood Pressure, Congenital Heart Disease, Diabetes ) * Please list any gastric surgeries you have had. * Please list any cosmetic / aesthetic surgeries you have had. * Please list any surgeries other than cosmetic / gastric surgeries you have undergone. * Please list all medications with dosages that you are currently taking. * If you are female, how many pregnancies to term have you had? * Do you have any blood or blood clotting disorders? * Have you had herpes in the past ? * Yes No Are you HIV positive? * Yes No Are you Hepatitis B positive? * Yes No Are you Hepatitis C positive? * Yes No Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? * Yes No If yes, to any of the above, what is your current status (virus free, cured, taking meds)? * Have you had any problems with anesthesia in the past? * Yes No If yes what happened and with what anesthesia agent? * Can you take morphine? * Yes No Can you take demerol? * Yes No Can you take epinephrine? * Yes No Do you have dry eyes? * Yes No Do you have lens implants in your eyes? * Yes No Have you ever been told you had an adhesive allergy? * Yes No Are you allergic to medical tape? * Yes No Latexallergy? * Yes No Do you have sleep apnea? * Yes No If yes, do you wear CPAP at night? * Yes No Have you ever had a blood clot in your calf? * Yes No Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)? * Yes No Anemia? * Yes No Rectal Bleeding? * Yes No Constipation or Diarrhea? * Yes No Oral antidiabetic pills? * Yes No Insulin? * Yes No Any drug allergies / adverse drug reactions? * Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics? * Notes * Section Buttons Submit Submit If you are human, leave this field blank. 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