CLINIQUEPLUS Patient Info Form

First Name*

Last Name*

Height*

Weight*

Age*

Gender*

Is there a known pregnancy?*

Are you allergic to any food and/or medication?*

Do you smoke or consume tobacco products? If your answer is yes please specify your daily intake.* Do you consume alcohol? If so please specify how often and how much you consume?* Do you regularly use drugs? Or have you used it within the last two weeks?* Do you have blood-based chronic disease such as HIV / Hepatitis B / Hepatitis C? Is there a known cancerous disease? If so, please define that what you have* Do you have any disease? If so, please define that what you have* Do you have any medicine/drugs that you use regularly? If so, please explain which ones you are taking.* 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?* Have you ever been put under general anesthesia? If you have, did you encounter any health related issues during or after receiving general anesthesia?* Have you ever been tested positive for Covid-19? If yes, when?* Is there anything else you would like to add? (Vegan/Vegetarian/Lactose intolerance)* Please choose your Patient Coordinator I do approve every information that I gave above this is true.

CLINIQUEPLUS Patient Info Form

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