Patient Registration Form

Have You Been Blood Transfusions?
I have a blood transfusion. I haven´t had a blood transfusion

Have you been exposed to a dangerous chemical?
I was exposed to a dangerous chemical. I was not exposed to a dangerous chemical.

Did you stay in the hospital on boarding?
I stayed in the hospital on boarding. I didn´t stay in the hospital on boarding.

Have you ever had a Deep Vein Thrombosis (DVT)?
I´ve had DVT in the past. I have never had DVT.

Smoking
I smoke. I don´t smoke

Alcohol
I drink alcohol. I don´t drink alcohol. I used alcohol in the past. I have not used alcohol in the past.

Drug
I use drugs. I don´t use drugs I used drugs in the past. I´ve never used drugs.

Your primary language choice for which you would like to be contacted?
Turkish English