Izmir / Turkey +90 535 438 01 87

MEDICAL HISTORY FORM

PLEASE ANSWER AS FULLY AND AS ACCURATELY AS POSSIBLE TO ENABLE OUR SURGEON TO ESTABLISH ANY POTENTIAL REASON WHILST YOU WOULD NOT BE SUITABLE FOR SURGERY.

SELECTION OF SURGERY:

MEDICAL HISTORY



Please list any allergies to medications you have.

Please list any medical conditions you have – heart disease, hypertension, kidney disease,
cancer, diabetes, hepatitis, seizures, depression etc.

Please list any cosmetic surgeries you have had.

Please list any surgeries other than cosmetic surgeries you have undergone.

Please list all medications with dosages that you are currently taking.

If you are female, how many pregnancies to term have you had?

Do you have any blood or blood clotting disorders?
YesNo

Do you smoke cigarettes on a daily basis?
YesNo

Do you drink more than 2oz of alcohol/day?
YesNo
Have you had outbreaks of oral herpes in the past (cold sores around the mouth)?
YesNo
Are you HIV positive?
YesNo
Are you Hepatitis B positive?
YesNo
Are you Hepatitis C positive?
YesNo
Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)?
YesNo
If yes, to any of the above, what is your current status (virus free, cured, taking meds)?

Have you had any problems with anesthesia in the past?
YesNo

Can you take morphine?
YesNo
Can you take demerol?
YesNo
Can you take epinephrine?
YesNo
Do you have dry eyes?
YesNo
Do you have lens implants in your eyes?
YesNo
Have you ever been told you had an adhesive allergy?
YesNo
Allergy to tape?
YesNo
Latexallergy?
YesNo
Do you have sleep apnea?
YesNo
If yes, do you wear CPAP at night?
YesNo
Have you ever had a blood clot in you calf?
YesNo
Have you ever had a blood clot(s) that went to your lungs (pulmonary embolus)?
YesNo

PERSONAL INFORMATION



Copyright by © Get Slim in Turkey / Designed by Ada Dizayn