Medical History Form
Full Name
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Email Address
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a valid email address
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Phone
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Street Address
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City
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4
Country
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
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Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
People's Republic of China
Colombia
Comoros
(Congo ヨ Kinshasa) Congo
(Congo ヨ Brazzaville) Congo
Costa Rica
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Croatia
Cuba
Cyprus
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Equatorial Guinea
Eritrea
Estonia
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Fiji
Finland
France
Gabon
The Gambia
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Guinea
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Hungary
Iceland
India
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Iran
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Laos
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Liberia
Libya
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Lithuania
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste (East Timor)
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Abkhazia
Republic of (Taiwan) China
Nagorno-Karabakh
Northern Cyprus
Pridnestrovie (Transnistria)
Somaliland
South Ossetia
Ashmore and Cartier Islands
Christmas Island
Cocos (Keeling) Islands
Coral Sea Islands
Heard Island and McDonald Islands
Norfolk Island
New Caledonia
French Polynesia
Mayotte
Saint Barthelemy
Saint Martin
Saint Pierre and Miquelon
Wallis and Futuna
French Southern and Antarctic Lands
Clipperton Island
Bouvet Island
Cook Islands
Niue
Tokelau
Guernsey
Isle of Man
Jersey
Anguilla
Bermuda
British Indian Ocean Territory
British Sovereign Base Areas
British Virgin Islands
Cayman Islands
Falkland Islands (Islas Malvinas)
Gibraltar
Montserrat
Pitcairn Islands
Saint Helena
South Georgia & South Sandwich Islands
Turks and Caicos Islands
Northern Mariana Islands
Puerto Rico
American Samoa
Baker Island
Guam
Howland Island
Jarvis Island
Johnston Atoll
Kingman Reef
Midway Islands
Navassa Island
Palmyra Atoll
U.S. Virgin Islands
Wake Island
Hong Kong
Macau
Faroe Islands
Greenland
French Guiana
Guadeloupe
Martinique
Reunion
Aland
Aruba
Netherlands Antilles
Svalbard
Ascension
Tristan da Cunha
Australian Antarctic Territory
Ross Dependency
Peter I Island
Queen Maud Land
British Antarctic Territory
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Date of Birth
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Gender
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select just one
Female
Male
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Weight (Kg)
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Height (Meter / Cm)
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Are you currently receiving treatment from a doctor, hospital a clinic?
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select just one
Yes
No
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If "Yes" please give any details:
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Have you ever been pregnant? If yes how many times? (C-section or Normal?)
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Are you pregnant or possibly pregnant?
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Chronical Diseases
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select one or more
Hypertension
Diabetes - Type 1
Diabetes - Type 2
Heart Disease
Asthma
Kidney Disease
Liver Disease (Hepatitis - Jaundice)
HIV+ or AIDS
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Autoimmune Disorders
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Psoriasis
Graves' disease (hyperthyroidism)
Hashimoto's thyroiditis (hypothyroidism)
Multiple sclerosis
Inflammatory bowel syndrome
Lupus
Rheumatoid arthritis
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Respiratory Diseases
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Shortness of breath
Asthma
Bronchitis
Pneumonia
Chronic Obstructive Pulmonary Disease (COPD)
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Digestive system disorders
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Constipation
Diarrhea
Acid reflux
Irritable Bowel Syndrome (IBS)
Peptic ulcer
Celiac disease
Crohn's Disease
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Musculoskeletal Disorders
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Carpal tunnel syndrome
Herniated disc
Degenerative disc disease
Osteoporosis
Rheumatoid arthritis
Chronic myofascial pain
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Blood Cell Disorders
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Iron-deficiency anemia
Chronic Anemia
Pernicious anemia (B12 deficiency)
Aplastic anemia
Thalassemia
Sickle cell anemia
Idiopathic thrombocytopenic purpura
Hemophilia
Deep venous thrombosisOption
Disseminated intravascular coagulation (DIC)
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Central Nervous System Disorders
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Alzheimer's disease
Epilepsy
Multiple sclerosis (MS)
Parkinson's disease
Migraine
Sciatica
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Psychological Disorders
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Depression
Anxiety
Bipolar disorder
Borderline personality disorder
Panic Disorder
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A bad reaction to general or local anesthenic?
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22
Alcohol consumption?
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select just one
Yes
No
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How many units of alcohol do you drink per week?
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Do you smoke tobacco products now (or did you in the past)?
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select just one
Yes
No
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How many times per day?
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Are you currently taking any medication ? Please specify them here.
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Please specify your past surgeries plastic ones and others.
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Do you have any allergies. Write them down here.
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Do you have hyperthyroid or hypothyroid? Do you take medication for it? If yes, please specify them.
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Do you take any hormone replacement therapy, estrogen gels or pills or contraceptive pills.
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Are you suffering from hernia?
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How did you reach Opr. Dr. Baran Kul brand ?
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Submit
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