Health Check Form

Name
Surname
Height
Weight
BMI Index
Address/City/State
Country
Mobile
1.Have you had any operations?
2. Have you ever been hospitalized for reasons other than operations?
Please list all medicines you take now and specify doses: (include over-the-counter medicines and supplements)
Please list any allergies or reactions

 

Blood transfusion
YesNo
Anemia
YesNo
Arthritis
YesNo
Asthma/Emphysema
YesNo
Bladder or Kidney Infections
YesNo
Blood Clots / Bleeding disorders
YesNo
Chronic Diarrhea
YesNo
Diverticulosis
YesNo
Diabetes
YesNo
Epilepsy or Seizures
YesNo
Gallstones / Gallbladder Disease
YesNo
Gout
YesNo
Heart Disease
YesNo
Cholesterol
YesNo
High Blood Pressure
YesNo
Kidney Disease/Stones
YesNo
Liver Disease/Hepatitis
YesNo
Lung Disease/Pneumonia
YesNo
Polyps
YesNo
Rheumatic Fever
YesNo
Sleep apnea
YesNo
Stroke
YesNo
Thyroid Disease/Goiter
YesNo
Ulcers (stomach or intestinal)
YesNo
Reflux
YesNo
Sexually-transmitted disease
YesNo
Smoking:
Do you smoke?
YesNo
Alcohol:
Do you drink alcohol?
YesNo
Drugs:
Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills?
If yes, please specify types, quantity and duration of use

Please fill in all space and submit.