ANADOLU MEDICAL CENTER MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES MEDICAL SECOND OPINION REQUEST FORM

PLEASE COMPLETE ALL OF THE FIELDS IF POSSIBLE TO GET A DETAILED MEDICAL SECOND OPINION

Name-Surname: Gender: Year of birth: Country: Profession:

Application Date:

Reason for application to Anadolu Medical Center:

Present Medical Problems:

Please list any known medical problems that you have at present Medical Problem Date of Onset

PRESENT ILLNESS

Current Medications:

Please list all medications that you are taking currently (antibiotics, antihypertensive drugs, chemotherapy medicines, blood thinners etc.) Medicine Name Dosage Date Started

Address: Cumhuriyet Mahallesi 2255 Sk No: 3, Gebze 41400 / Kocaeli, TURKEY 1/5 F-1994-00

ANADOLU MEDICAL CENTER MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES MEDICAL SECOND OPINION REQUEST FORM
Please list in chronological order the surgeies or interventions (if any) you have had. Name of the Surgery/Intervention Year

Please indicate the radiological examinations performed in chronological order. Type Of Radiological Examination Year Result

PAST MEDICAL HISTORY

Other examinations or interventions:

Please indicate pathology results if any: Type Of Pathological Examination Date Result

Please indicate past medications (especially blood thinners, chemotherapy medicine etc.) if any. Medicine Name Dosage Date Started

Address: Cumhuriyet Mahallesi 2255 Sk No: 3, Gebze 41400 / Kocaeli, TURKEY 2/5 F-1994-00

ANADOLU MEDICAL CENTER MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES MEDICAL SECOND OPINION REQUEST FORM
Please list radiotherapy dosages if any. PAST MEDICAL HISTORY Radiotherapy Dosage Date Started Date Ended

Do you smoke? Please indicate as Yes or No:

Yes

No

General 1. Unexplained weight loss? 2. Fatigue? 3. Change in appetite? 4. Night sweats? 5. Fever or chills? 6. Any type of cancer? Heart / Vascular 1. Chest pain/pressure 2. Heart attack REVIEW OF SYSTEMS 3. Rapid/irregular heart beats? 4. Fainting? 5. High blood pressure? Eyes 1. Double vision? 2. Glaucoma? 3. Cataracts? Ear Nose And Throat 1. Hearing loss? 2. Ringing in the ears? 3. Chronic ear infections? 4. Snoring and sleep apnea? 5. Nasal drainage? 6. Throat pain? 7. Nosebleeds?

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Address: Cumhuriyet Mahallesi 2255 Sk No: 3, Gebze 41400 / Kocaeli, TURKEY 3/5 F-1994-00

ANADOLU MEDICAL CENTER MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES MEDICAL SECOND OPINION REQUEST FORM
Bone And Joint 1. Chronic joint and muscle pain? 2. Low back pain? 3. Swollen joints? Endocrine 1. Thyroid disease? 2. High blood sugarDiabetes? Pulmonary 1. Chronic cough? 2. Wheezing? 3. Asthma? 4. Tuberculosis? 5. Bronchitis? 6. Pneumonia? REVIEW OF SYSTEMS 7. Coughed up blood? 8. Shortness of breath? Gastrointestinal 1. Frequent heartburn? 2. Abdominal pain? 3. Vomited blood? 4. Jaundice? 5. Diarrhea? 6. Constipation? Neurology 1. Loss of consciousness 2. Vertigo? 3. Memory problems? 4. Seizures or epilepsy? 5. Headache? 6. Numbness of arms, legs, fingers, toes, face? Hematology 1. Anemia ? 2. Bleeding disorder? 3. Enlarged lymph nodes?
Address: Cumhuriyet Mahallesi 2255 Sk No: 3, Gebze 41400 / Kocaeli, TURKEY 4/5 F-1994-00

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

ANADOLU MEDICAL CENTER MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES MEDICAL SECOND OPINION REQUEST FORM

Dermatology 1. Skin rash? 2. Skin sores that wont heal? 3. Shingles/ herpes? 4. Unusual moles? 5. Mouth sores that wont heal? 6. Other? Urology 1. Blood in urine ? REVIEW OF SYSTEMS 2. Burning or pain while urinating? 3. Kidney stones? 4. Difficulty urinating Other notes and requests:

Yes

No

Dont Know

If yes, please indicate since when

Yes

No

Dont Know

If yes, please indicate since when

Thank you for your time and patience in completing this questionnaire.

Address: Cumhuriyet Mahallesi 2255 Sk No: 3, Gebze 41400 / Kocaeli, TURKEY 5/5 F-1994-00