Sağlık Kontrol Formu 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 * 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. Δ
