MEDICAL HISTORY FORM

Full Name*

Email Address*

Phone*

Street Address

Country

City

Date of birth

Weight(Kg)*

Height (Meter/Cm)

Gender FemaleMale

Are you currently receiving treatment from a doctor, hospital a clinic?* YesNo

Have you ever been pregnant? If yes how many times? (C-section or Normal?)*

Are you pregnant or possibly pregnant?

!!!!!!!!!

Chronical Diseases HypertensionDiabetes - Type 1Diabetes - Type 2Heart DiseaseAsthmaKidney DiseaseLiver Disease (Hepatitis - Jaundice)HIV+ or AIDS

Autoimmune Disorders PsoriasisGraves' disease (hyperthyroidism)Hashimoto's thyroiditis (hypothyroidism)Multiple sclerosisInflammatory bowel syndromeLupusRheumatoid arthritis

Respiratory Diseases Shortness of breathAsthmaBronchitisPneumoniaChronic Obstructive Pulmonary Disease (COPD)

Digestive system disorders Carpal tunnel syndromeHerniated discDegenerative disc diseaseOsteoporosisRheumatoid arthritisChronic myofascial pain

Musculoskeletal Disorders ConstipationDiarrheaAcid refluxIrritable Bowel Syndrome (IBS)Peptic ulcerCeliac diseaseCrohn's Disease

Blood Cell Disorders Iron-deficiency anemiaChronic AnemiaPernicious anemia (B12 deficiency)Aplastic anemiaThalassemiaSickle cell anemiaIdiopathic thrombocytopenic purpuraHemophiliaDeep venous thrombosis optionDisseminated intravascular coagulation (DIC)

Central Nervous System Disorders Alzheimer's diseaseEpilepsyMultiple sclerosis (MS)Parkinson's diseaseMigraineSciatica

Psychological Disorders DepressionAnxietyBipolar disorderBorderline personality disorderPanic Disorder

A bad reaction to general or local anesthenic?

Alcohol consumption?* YesNo

How many units of alcohol do you drink per week?

Do you smoke tobacco products now (or did you in the past)?* YesNo

How many times per day?

Are you currently taking any medication ? Please specify them here.

Please specify your past surgeries plastic ones and others.

Do you have any allergies. Write them down here.

Do you have hyperthyroid or hypothyroid? Do you take medication for it? If yes, please specify them.

Do you take any hormone replacement therapy, estrogen gels or pills or contraceptive pills.

Are you suffering from hernia?

How did you reach Opr. Dr. Baran Kul brand?

The Coolest Clinic is an accredited medical travel and intermediary company with the code 13066, with the membership of TÜRSAB (Association of Turkish Travel Agencies) by the Ministry of Health.