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MEDICAL HISTORY FORM
Full Name*
Email Address*
Phone*
Street Address
Country
City
Date of birth
Weight(Kg)*
Height (Meter/Cm)
Gender
Female
Male
Are you currently receiving treatment from a doctor, hospital a clinic?*
Yes
No
Have you ever been pregnant? If yes how many times? (C-section or Normal?)*
Are you pregnant or possibly pregnant?
!!!!!!!!!
Chronical Diseases
Hypertension
Diabetes - Type 1
Diabetes - Type 2
Heart Disease
Asthma
Kidney Disease
Liver Disease (Hepatitis - Jaundice)
HIV+ or AIDS
Autoimmune Disorders
Psoriasis
Graves' disease (hyperthyroidism)
Hashimoto's thyroiditis (hypothyroidism)
Multiple sclerosis
Inflammatory bowel syndrome
Lupus
Rheumatoid arthritis
Respiratory Diseases
Shortness of breath
Asthma
Bronchitis
Pneumonia
Chronic Obstructive Pulmonary Disease (COPD)
Digestive system disorders
Carpal tunnel syndrome
Herniated disc
Degenerative disc disease
Osteoporosis
Rheumatoid arthritis
Chronic myofascial pain
Musculoskeletal Disorders
Constipation
Diarrhea
Acid reflux
Irritable Bowel Syndrome (IBS)
Peptic ulcer
Celiac disease
Crohn's Disease
Blood Cell Disorders
Iron-deficiency anemia
Chronic Anemia
Pernicious anemia (B12 deficiency)
Aplastic anemia
Thalassemia
Sickle cell anemia
Idiopathic thrombocytopenic purpura
Hemophilia
Deep venous thrombosis option
Disseminated intravascular coagulation (DIC)
Central Nervous System Disorders
Alzheimer's disease
Epilepsy
Multiple sclerosis (MS)
Parkinson's disease
Migraine
Sciatica
Psychological Disorders
Depression
Anxiety
Bipolar disorder
Borderline personality disorder
Panic Disorder
A bad reaction to general or local anesthenic?
Alcohol consumption?*
Yes
No
How many units of alcohol do you drink per week?
Do you smoke tobacco products now (or did you in the past)?*
Yes
No
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?