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Patient Info Form
Patient Health Form
Name
(Required)
First
Last
Weight
(Required)
Height
(Required)
Age
(Required)
Gender
(Required)
Male
Female
Are you allergic to any food and/or medication?
(Required)
Is there a pregnancy?
(Required)
Yes
No
Do you smoke or consume tobacco products? If your answer is yes please specify your daily intake.
(Required)
Do you consume alcohol? If so please specify how often and how much you consume?
(Required)
Do you regularly use drugs? Or have you used it within the last two weeks?
(Required)
Do you have blood-based chronic disease such as HIV / Hepatitis B / Hepatitis C?
(Required)
Yes
No
Is there a known cancerous disease? If so, please define that what you have.
(Required)
Do you have any disease? If so, please define that what you have.
(Required)
Do you have any medicine/drugs that you use regularly? If so, please explain which ones you are taking.
(Required)
Have you ever undergone surgery? Please list all surgeries you have undergone including dates. Did you face any health-related issues during or after the operation/operations?
(Required)
Have you ever been put under general anesthesia? If you have, did you encounter any health related issues during or after receiving general anesthesia?
(Required)
Have you ever been tested positive for Covid-19? If yes, when?
(Required)
Is there anything else you would like to add? (Vegan/Vegetarian/Lactose intolerance)
(Required)
Please choose your Patient Coordinator
(Required)
Fatih
Belma
Defne
Lale
Eylül
Confirmation
(Required)
I do approve every information that I gave above this is true.
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