Medical Form

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Could you please answer these questions? It is required for your assesment. Do not forget to answer all the questions, even if the answer is no.

Full Name

Date of Birth

Which country are you a citizen of?

Weight

Height

Do you have any chronic disease? (Diabetes, High blood pressure, Thyroid Disease, Arthritis, Kidney Disease, HIV, Hepatitis, Stomach Ulcers, …)

Do you use any medication?

Have you ever had a Stroke?

Do you have any allergies?

Have you had any previous surgeries? If yes, please specify.

Have you had covid 19 before? İf yes when? Are you vaccinated against Covid?

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you consume recreational drugs or other?

Do you have any implants (dental implants, lenses, prosthesis, hearing aid device and etc) in your body?

Do you have children? If yes, when was the last time you gave birth?

Do you take birth control pill? Do you have a contraceptive implant? Or other?

You can upload your photos to this area. (It is not mandatory.) You can also send it to your personal advisor.

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