Preoperative Health Survey Please enable JavaScript in your browser to complete this form. – Step 1 of 4Primary Contact Name *FirstLastPrimary Contact Email *Primary Contact PhoneSecondary Contact Phone (Your companion, Friend or Family member)Your planned surgery(s)?When are you planning your surgery?İleriDo you have any of these medical conditions?DiabetesHeart diseaseLow blood countAsthma or and other breathing problemsThyroid diseaseVaricose Vein diseaseHepatitis or any other liver diseaseRomatological Diseases (Romathoid Artritis, Lupus etc…)Sickle Cell AnemiaThalessemiaChemotheraphyDo you have any other health conditions not listed above?Do you have any Allergies?Any previous surgeries? (Please include date)Do you use any medicines?AspirinBlood thinners (e.g. warfarin, coumadine, eneoxaparin etc)Thyroid medicinesBirth Control pills or any other hormon containing medicine or devicesSteroidsSupplements, vitamines, herbal teasOtherPlease list all the medicines you use.İleriYour Age?Your height?Your Weight?Smoking, Waping , Alcohol consumption? (please describe)You are planning to have your vacation…AloneWith a companionİleriFinally, would you like to point out another situation that you think may be important regarding your health and your trip?Submit
