Şemikler Mah. 6223/ 2 Sok No: 5 D:3 Karşıyaka / İzmir
+90 542 125 91 07
info@fideshealthinternational.com

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Tıbbi Bölümler
Anlaşmalı Kurumlarımız
Ülke Temsilciliklerimiz
Hizmet Trafiği
Fides Haberler
Sağlık Kontrol Formu
İletişim
Türkçe

Sağlık Kontrol Formu

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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

Last

Email *

Phone Number *

Address *

Address

City

State/Province

Zip/Postal

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 *

If you are human, leave this field blank.

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Adres: Şemikler Mah. 6223/ 2 Sok No: 5 D:3 – Karşıyaka/İzmir

+90 542 125 91 07
info@fideshealthinternational.com

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