OUR CONTRACTED DOCTORS
MEDICAL HISTORY FORM
Date of birth
Are you currently receiving treatment from a doctor, hospital a clinic?*
Have you ever been pregnant? If yes how many times? (C-section or Normal?)*
Are you pregnant or possibly pregnant?
Diabetes - Type 1
Diabetes - Type 2
Liver Disease (Hepatitis - Jaundice)
HIV+ or AIDS
Graves' disease (hyperthyroidism)
Hashimoto's thyroiditis (hypothyroidism)
Inflammatory bowel syndrome
Shortness of breath
Chronic Obstructive Pulmonary Disease (COPD)
Digestive system disorders
Carpal tunnel syndrome
Degenerative disc disease
Chronic myofascial pain
Irritable Bowel Syndrome (IBS)
Blood Cell Disorders
Pernicious anemia (B12 deficiency)
Sickle cell anemia
Idiopathic thrombocytopenic purpura
Deep venous thrombosis option
Disseminated intravascular coagulation (DIC)
Central Nervous System Disorders
Multiple sclerosis (MS)
Borderline personality disorder
A bad reaction to general or local anesthenic?
How many units of alcohol do you drink per week?
Do you smoke tobacco products now (or did you in the past)?*
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?