Dr. Safa Manav Patient Info Form Patient Health Form Name(Required) First Last Weight(Required)Height(Required)Age(Required)Gender(Required) Male Female Are you allergic to any food and/or medication?(Required)Is there a pregnancy?(Required) Yes No Do you smoke or consume tobacco products? If your answer is yes please specify your daily intake.(Required)Do you consume alcohol? If so please specify how often and how much you consume?(Required)Do you regularly use drugs? Or have you used it within the last two weeks?(Required)Do you have blood-based chronic disease such as HIV / Hepatitis B / Hepatitis C?(Required) Yes No Is there a known cancerous disease? If so, please define that what you have.(Required)Do you have any disease? If so, please define that what you have.(Required)Do you have any medicine/drugs that you use regularly? If so, please explain which ones you are taking.(Required)Have you ever undergone surgery? Please list all surgeries you have undergone including dates. Did you face any health-related issues during or after the operation/operations?(Required)Have you ever been put under general anesthesia? If you have, did you encounter any health related issues during or after receiving general anesthesia?(Required)Have you ever been tested positive for Covid-19? If yes, when?(Required)Is there anything else you would like to add? (Vegan/Vegetarian/Lactose intolerance)(Required)Please choose your Patient Coordinator(Required) Fatih Belma Defne Emre Serhat Confirmation(Required) I do approve every information that I gave above this is true.
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