Medical History Form

Prime Assist Health – Plastic Surgery Clinic in Turkey  >  Medical History Form

Medical History Form

Name Surname *

Email *

Phone Number *

Country *Country USAUnited KingdomAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCabo VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamYemenZambiaZimbabwe

Birthday *

Height (Cm's) * *

Weight (Kg's) *

Have You Ever Had (Please Check All That Apply)

Anemia *

• Yes
• No

Asthma *

• Yes
• No

Arthritis *

• Yes
• No

Cancer *

• Yes
• No

Diabetes *

• Yes
• No

Psychiatric Disorder *

• Yes
• No

Epilepsy Seizures *

• Yes
• No

Fainting Spells *

• Yes
• No

Gallstones *

• Yes
• No

Heart Murmur *

• Yes
• No

Cardiac Disease *

• Yes
• No

Rheumatic Fever *

• Yes
• No

High Blood Pressure *

• Yes
• No

Digestive Problems *

• Yes
• No

Chest Pain *

• Yes
• No

Ulcer Disease *

• Yes
• No

Hepatitis *

• Yes
• No

HIV *

• Yes
• No

Bleeding Tendency *

• Yes
• No

Kidney Stones *

• Yes
• No

Blood Transfussion *

• Yes
• No

Sleep Apnea *

• Yes
• No

Thyroid Problems *

• Yes
• No

Shortness of Breath *

• Yes
• No

Hernia Repair *

• Yes
• No

Blood in Urine *

• Yes
• No

Anesthetic Reaction *

• Yes
• No

Lung Disease *

• Yes
• No

Blood with Coughing *

• Yes
• No

Sickle Cell *

• Yes
• No

Sickle Cell Trait *

• Yes
• No

Thalassemia *

• Yes
• No

Other Illnesses If Applicable

What's Your Requested Treatment? *

Patient Medical History

Are You Allergic To Any Medication?

Have You Had Any Previous Surgery? (If Yes, Please State Including The Dates)

Please List Your Current Medications That You Are Taking?

Are You Taking Any Herbal Supplements & Multivitamins?

Are You On Any Kind Of Birth Control Or Hormones? (Pills, Implants, Patch, Depot Injections, Coils Etc.?

Have You Ever Given Birth Before? If Yes, Kindly State The Date/S And The Type/S Of Delivery.

Healthy & Unhealthy Habits

Exercise *Please SelectNever1-2 days/week3-4 days/week5+ days/week

Are You On Any Diet? *Please SelectI have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption *Please SelectI don't drink1-2 glasses/week3-4 glasses/week5+ glasses/weekOccasionally

Do You Use Or Do You Have A History Of Using Recreational Drugs? *Please SelectYesNo

Do You Smoke? *Please SelectI don't smoke1-5 cigarettes/day5-10 cigarettes/day10-20 cigarettes/day

How Did You Learn About Us? *Please SelectSomeone else suggestedOnline AdsInstagramOther Social Media'sSearch Engine Motors

Include Other Comments Regarding Your Medical History

Acceptence *

• I accept and declare that all the information I have provided is correct. Responsibilities that may arise from all incomplete or incorrect information belong to the patient and Prime Assist Health does not accept any kind of liability. By clicking Submit, you agree to our You must accept the Privacy Policy to continue. By clicking Submit, you agree to our Terms and Conditions and that you have read our Privacy Policy.
  Note: We value your privacy! The medical history form you filled out is for only assessment purposes and never shared with third parties.

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