Name - Surname
Phone
Date of Birth
Your Address?
Your email address?
Your height in centimetres?
Your weight in kg?
Your blood type?
Have you ever given birth? If yes, which year?
Do you have any contagious diseases? If yes, please explain the details.
Have you ever been tested positive for Covid-19?
Past Medical History that needs mention?
Do you have any chronic diseases? If yes, please explain the details.
Do you use any medication daily or often? If yes,please explain the details.
Have you ever had any surgeries before? If yes, please write down what procedure and when it was
Do you have any allergies? If yes, please give details
Do you use contraceptives? (Birth contol method)
Do you smoke?
Do you use alcohol?
Do you drink energy drinks?
Do you use vitamin or food supplements?
Do you use soft or hard drugs? (Answering this questions honestly, has vital importance!)
Do you have psychological problem as anxiety or depression?
Have you or your family ever had difficulties with General Anesthetic?
Emergency contact person name and phone
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