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Medical Information Chart

Personal information
  • Please enter a Valid Phone Number!
Medical information
Have you ever given birth?
Do you have HIV
Do you have Hepatitis B
Do you have Hepatitis C
Do you have any other contagious diseases?
Have you had the following?
Chest Pain
Breast Disease
Any Seizures
Heart Murmur
Thyroid Disorder
Any Scarring Problem
Hight Blood Pressure
Anaemia
Diabetes
Cancer
Asthma
Dryness of Eyes
Bleeding Disorders
Do you have any other chronic diseases?
Do you you use any medication daily or often? (Including aspirin and and non-prescription medicine)
Have you ever had any surgeries before?
Do you have any allergies? (Including latex)
Do you use contraceptives (Birth control medicine)
Do you smoke?
Do you consume alcohol?
Do you drink energy drinks?
Do you use any vitamin or supplement? (especially Gingko, Ginger, Garlic, St. John’s Wort, C, E, Fish oils)
Do you use any drug? *Answering this question honestly has vital importance!
Do you have any psychological disorder such as anxiety or depression?
Have you or your family member ever had any problem during general anaesthesia?
Could you write the names and phone numbers of two acquaintances we can reach in case of emergency?
  • Please enter a Valid Phone Number!
  • Please enter a Valid Phone Number!
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Hair Treatments
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Dental Treatments
All on 4 Dental ImplantsDental CrownDental BridgeTeeth WhiteningDental VeneerTooth ExtractionSmile MakeoverGum ContouringRoot Canal TreatmentDental Implant
Metabolic Surgery
Gastric Balloon SurgeryGastric Bypass SurgeryGastric Sleeve Surgery
Eye Diseases
Lasik Eye Surgery
Contact
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Suadiye/Kadıköy/İstanbul Telephone
+90 536 608 82 71 E-Mail
info@healtripglobal.com
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