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    PATIENT DETAILS







    MEDICAL INFORMATION

    (DO YOU HAVE OR HAVE YOU HAD)

    AIDS/HIV+YesNo

    AnemiaYesNo

    ArthritisYesNo

    AsthmaYesNo

    Back ProblemsYesNo

    Bladder InfectionYesNo

    Bleeding Tend.YesNo

    Blood ClotsYesNo

    BronchitisYesNo

    History of cancerYesNo

    DiabetesYesNo

    High Blood PressureYesNo

    ColitisYesNo

    Congenital HeartYesNo

    EpilepsyYesNo

    Fainting SpellsYesNo

    GoiterYesNo

    Hay FeverYesNo

    HepatitisYesNo

    Kidney DiseaseYesNo

    Liver DiseaseYesNo

    LeukemiaYesNo

    MigraineYesNo

    Nervous BreakdownYesNo

    PneumoniaYesNo

    PalpitationsYesNo

    Pain in the ChestYesNo

    Rheumatic HeartYesNo

    Shortness of breathYesNo

    Stomach UlcersYesNo

    Stroke HistoryYesNo

    Thyroid DiseaseYesNo

    TuberculosisYesNo

    Cold or flu recently?YesNo

    Heart Attack History?

    YesNo

    Do you have any metal implants/devices?

    YesNo


    Do you smoke?

    YesNo

    Drink alcohol?

    YesNo








    PAST SURGERIES & ANAMNESIS



    Bad reactions to anesthesia?

    YesNo

    WOMEN ONLY

    Pregnant?

    YesNo


    Regular periods?

    YesNo



    SLEEP APNEA SYMPTOMS

    Tired upon wakingYesNo

    Trouble staying asleepYesNo

    Told that I snoreYesNo

    Arms/legs jerkYesNo

    Revitalize In Turkey is a trusted medical tourism brand with over 21 years of experience. We connect international patients with top surgeons and accredited healthcare facilities in Turkey, providing safe, personalized and high-quality aesthetic treatments.

    Turkey Head Office

    Ayşe Mayda Street, No:15c
    Küçükyalı, Konak, İzmir – Turkey

    Mandarin Grove Health & Wellness Retreat

    Atatürk District, 2175 Street, No:79
    Urla, İzmir – Turkey