TR EN
Request an appointment

Medical Information Chart

Personal information
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
High blood pressure
Anaemia
Diabetes
Cancer
Asthma
Dryness of eyes
Bleeding disorders
Do you have any other chronic diseases?
Do you use any medication daily or often? (Including aspirin 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 Ginkgo, 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?
Emergency contacts

Could you write the name and phone number of an acquaintance we can reach in case of emergency? A second contact is optional.

REQUEST A CONSULTATION

Book a consultation

Fill in the form and our team will call you.