Health Check Form Home » Health Check Form Obesity Name Surname Email Birth Day Occupation Height Weight BMI Index Country Country Code Phone Number Address Have you had any operations? 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 No Yes Anemia No Yes Asthma/Emphysema: No Yes Arthritis: No Yes Bladder or Kidney Infections No Yes Blood Clots/Bleeding disorders No Yes Chronic Diarrhea No Yes Diverticulosis No Yes Diabetes No Yes Epilepsy or Seizures No Yes Gallstones/Gallbladder Disease No Yes Gout No Yes Heart Disease No Yes Cholesterol No Yes High Blood Pressure No Yes Kidney Disease/Stones No Yes Liver Disease/Hepatitis No Yes Lung Disease/Pneumonia No Yes Polyps No Yes Rheumatic Fever No Yes Sleep apnea No Yes Stroke No Yes Thyroid Disease/Goiter No Yes Ulcers (stomach or intestinal) No Yes Reflux No Yes Sexually-transmitted disease No Yes Smoking No Yes Alcohol No Yes Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills? Message I agree to Terms and Conditions Send
