Health Check Form Home » Health Check Form Cosmetic Meritial Status Single Married Divorced Widowed Name Surname Email Birth Day Occupation Height Weight BMI Index Country Country Code Phone Number Address Smoking: (If yes, state quantity): Alcohol: (If yes, state quantity): Other Substances: (If yes, specify): Date of last menstrual period: Prescriptions/Medications: Number of pregnancies: Number of live births: Last childbirth (Date): Method of birth control: (Specify) If menopausal, date of onset: Drug Use: No Yes Drug allergies/adverse drug reaction: No Yes Reaction to Anaesthesia: No Yes Blood Transfusion: No Yes Sexually Transmitted Disease: No Yes Hepatitis: No Yes HIV: No Yes Breast Feeding: No Yes Hereditary health concerns: No Yes Diabet No Yes Insulin: No Yes Oral antidiabetic pills: No Yes Blood Pressure: No Yes Cancer: No Yes Kidney Disease: No Yes Epilepsy or Seizures: No Yes Anemia: No Yes Arthritis: No Yes Asthma/Emphysema: No Yes Difficulty in Swallowing/Stroke: No Yes Abnormal Vaginal Bleeding: No Yes Swollen Glands: No Yes Anxiety: No Yes Reflux: No Yes Chest Pain: No Yes Shortness of Breath: No Yes Difficulty Sleeping/Apnea: No Yes Nausea: No Yes Dizziness: No Yes Murmur (Heart Disease): No Yes Cardiac failure (Heart Disease): No Yes Rhythm disturbances (Heart Disease): No Yes Surgical history (State any surgical procedure): Surgical history date: Message I agree to Terms and Conditions Send
