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Home
Who We Are
Why Turkey
Hair Transplants
- Hair Transplant
- Afro-Textured Hair in Turkey
Cosmetic Procedures
MEN’s HEALTH
Medical Procedures
Forms
Contact Us

Form

ALLURE MED HEALTH QUESTIONNAIRE Form

Please enable JavaScript in your browser to complete this form.

I. Are you allergic to any of the following medications? YES/NO If YES, please mark below and state reactions: *

Penicillin Erythromycin?
Codeine?
Lidocaine?
Other:

Penicillin Erythromycin state

II. Have you ever had or been treated for any of the following?

1) Respiratory problems: including asthma, shortness of breath or chronic lung problems *

Yes
No

2) Cardiovascular problems: including chest pain, high blood pressure, heart attack, angina, heart valve problems, or stroke? *

Yes
No

3) Any dermatologic problems: including eczema, psoriasis, dandruff, or chronic rash? *

Yes
No

4) Any types of Hepatitis B or C, HIV or Acquired Immune Deficiency Syndrome (AIDS)? *

Yes
No

5) Any metabolic problems such as thyroid disease or diabetes? *

Yes
No

6) Any bleeding problems such as nosebleeds, easy bruising or anemia? *

Yes
No

7) Any mental health concerns such as depression, anxiety or panic disorder? *

Yes
No

8) Any immune system disorders? *

Yes
No

9) Please list any diseases that you have had or are being treated for that are not listed: *

10) Do you take any anticoagulants? (Aspirin, Coumadin, Plavix, Ibuprofen, Fish Oil, etc.)? *

Yes
No

11) Do you require preventative antibiotics prior to dental procedures, or have you had joint replacement or heart valve replacement? *

Yes
No

12) Please list ALL prescription, non-prescription, including anti-retroviral treatments and Prep/PEP and any herbal medications or supplements that you are currently or will be taking prior to surgery: *

13) Please list all previous surgeries, including previous hair transplant procedures: *

14) Any type of cancer, including skin cancer? *

Yes
No

chest 6) problems:

III. Weekly alcohol intake? *

When was your last intake? *

Weekly cigar/cigarette use? *

IV. Females only: Date of your last menstrual period? Are you pregnant? Are you breastfeeding?

By signing this form, I hereby confirm that I have read and answered all the questions correctly and I take whole responsibility for all the information I gave in this form. Also, I am aware of the consequences of providing wrong or false information or even not revealing the truthful information regarding my medical and health situation and that there might be consequences, including risk to my life and financial.

Name of Patient: *

First

Last

Date of Birth: *

Age: *

Signature of Patient: *

Clear Signature

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