• Full Name*
    0
  • Date of Birth*
    1
  • Gender*select just one
    Female
    Male
    2
  • Email Address*a valid email address
    3
  • Country*select your country
    4
  • How did you reach Hilde Health Travel?*
    5
  • Weight (Kg)*
    6
  • Height (Meter / Cm)*
    7
  • Covid-19*
    Yes
    No
    8
  • If yes, when you had Covid-19 ?*
    9
  • Do you have blood clot history or tendency ?*
    Yes
    No
    10
  • Do you suspect pregnancy ?*
    Yes
    No
    11
  • Do you have varicose vein problem ?*
    Yes
    No
    12
  • Heart Disease*
    Yes
    No
    13
  • High Blood Pressure*
    Yes
    No
    14
  • Shortness of Breath*
    Yes
    No
    15
  • Anesthetic Reaction*
    Yes
    No
    16
  • Diabetes*
    Yes
    No
    17
  • Nervous/Anxiety Disorder*
    Yes
    No
    18
  • Hempohilia*
    Yes
    No
    19
  • Sickle Cell Anemia*
    Yes
    No
    20
  • Are you taking birth control pills?*
    Yes
    No
    21
  • Are you taking blood thinner?*
    Yes
    No
    22
  • Please list all the medication names you are presently taking (including birth control tablets, contraceptive, etc)*
    23
  • Are you allergic to any food or drug? (Please list)*
    24
  • Do you smoke?*
    Yes
    No
    25
  • How much a day?*
    26
  • Did you have any surgery before?*
    Yes
    No
    27
  • If you had, please write down?*
    28
  • Do you have any disease that you consider as important to declare?*
    Yes
    No
    29
  • If you had, please write down*
    30
  • Files*for medical history files Upload
      31
    • *
      I READ AND ACCEPT TERMS AND CONDITION
      32
    • *
      I CONFIRM THAT THE INFORMATION I HAVE GIVEN ABOVE IS CORRECT
      33
    • 34