Personalized Check-up Pre-Assessment Form
This form helps us understand your age, medical history, family history, lifestyle, body measurements, current symptoms, and previous health information in order to create a more suitable check-up plan for you.
Within Health+, our aim is not to offer the same standard package to everyone, but to provide a more meaningful and targeted evaluation based on your personal risks.
This form is not intended for emergencies. If you have chest pain, severe shortness of breath, fainting, signs of stroke, confusion, severe bleeding, or sudden worsening of your general condition, please do not fill out this form and go to the emergency department.
Your phone / WhatsApp number
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Please measure at the level of your belly button using a measuring tape. If you are unable to measure it, you may leave this field blank.
Check-up Purpose and History
What is your reason for having a check-up?
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What is your reason for having a check-up?
What would you most like to learn after this check-up?
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What would you most like to learn after this check-up?
When was your last check-up or comprehensive blood test?
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When was your last check-up or comprehensive blood test?
Current Diseases and Medical History
Have you previously been diagnosed with any of the following conditions?
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Have you previously been diagnosed with any of the following conditions?
Have you ever had an important surgery or hospital admission?
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Have you ever had an important surgery or hospital admission?
If yes: Which surgeries or hospital admissions have you had?
What types of medications do you use regularly?
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What types of medications do you use regularly?
Do any of your first-degree relatives — mother, father, sibling, or child — have any of the following conditions?
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Do any of your first-degree relatives — mother, father, sibling, or child — have any of the following conditions?
If there is a history of cancer in your family, what type of cancer was it?
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If there is a history of cancer in your family, what type of cancer was it?
Do you currently have any symptom that bothers you?
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Do you currently have any symptom that bothers you?
Note: If you have chest pain, severe shortness of breath, fainting, signs of stroke, severe abdominal pain, bleeding, or any urgent condition, please go to the emergency department instead of filling out this form.
Lifestyle and Basic Risks
What is your physical activity level?
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What is your physical activity level?
How is your blood pressure usually?
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How is your blood pressure usually?
When was your last bone density measurement performed?
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When was your last bone density measurement performed?
When was your last colonoscopy or bowel cancer screening performed?
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When was your last colonoscopy or bowel cancer screening performed?
When was your last fecal occult blood test performed?
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When was your last fecal occult blood test performed?
Would you like to be evaluated for HPV, genital warts, or sexually transmitted infections?
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Would you like to be evaluated for HPV, genital warts, or sexually transmitted infections?
Recent Test and Report Upload
Do you have any blood tests, imaging results, or health reports performed within the last 3 months?
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Do you have any blood tests, imaging results, or health reports performed within the last 3 months?
If yes: You may upload your recent test results, imaging reports, or health documents.
If available, you may upload your blood tests, urine tests, ECG, echocardiography, ultrasound, mammography, smear/HPV test, bone density measurement, PSA, MRI/CT, doctor’s report, or discharge summary. These documents help us plan your check-up more accurately.
Is there any other information you would like to add?
The information you share in this form will only be used for check-up planning, preliminary evaluation, and contacting you. This form does not replace an emergency medical evaluation.
For any questions about your form, please contact:
Dr. Pelin Akman
Kamiloğlu Hospital Emergency Department
WhatsApp / Phone: +90 XXX XXX XX XX