Medical Form

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General Queries

First Name: *

Last Name: *

Date of birth: *

Intervention you have in mind: *

Marital Status: *

Occupation: *

Height (cm) / Weight (kg): *

Your email address: *

Past Medical History

Diabetes Mellitus:

típus:

Asthma:

type / medication:

High blood pressure:

how long / medication:

Heart disease:

explain ...:

Liver disease:

explain ...:

Kidney impairment:

explain ...:

Bleeding disorders:

explain ...:

Deep vein thrombosis (DVT):

explain ...:

Allergies:

explain ...:

Skin disorders:

explain ...:

Infectious disorders (Hepatitis, HIV):

Previous operations:

explain ...:

Previous anaesthesia:

any problems...:

Previous long-term hospitalization:

Pregnancy

Could you be pregnant?:

Previous pregnancies:

Number of children:

Mode of child birth:

Drug History

Regular medications:

Any current medication?:

Any known drug allergies?:

Family History

Any history of bleeding disorders:

if yes, explain:

Any history of breast disorders :

if yes, explain:

Any history of other disorders:

if yes, explain:

Current Medical History

Are you currently seeking any active form of treatment?:

Social History

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Medical tourism in Hungary

During Your stay we can organize a relaxing Wellness & Spa program, sightseeing tours in our stunning capital city or famous countries, visiting other spectacular attractions.
Receive a high standard beauty & health treatment and leave Hungary with the new you feeling - Look Amazing, Feel Gorgeous!

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