Mono Clinic

* Name

* Surname

* Email

Birth Day

Occupation

Height

Weight

BMI Index

Country

* Phone Number

Address/City/State

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

Anemia

Asthma/Emphysema

Arthritis

Bladder or Kidney Infections

Blood Clots/Bleeding disorders

Chronic Diarrhea

Diverticulosis

Diabetes

Epilepsy or Seizures

Gallstones/Gallbladder Disease

Gout

Heart Disease

Cholesterol

High Blood Pressure

Kidney Disease/Stones

Liver Disease/Hepatitis

Lung Disease/Pneumonia

Polyps

Rheumatic Fever

Sleep apnea

Stroke

Thyroid Disease/Goiter

Ulcers (stomach or intestinal)

Reflux

Sexually-transmitted disease

Smoking

Alcohol

Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills?

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Health Check Form

Plastic and Aesthetic Surgery

Dentistry & Obesity & Hair Transplant

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