Mobile Family Doctor Follow-up Request Form

This form is designed to create a mobile family doctor follow-up request for people who have difficulty leaving home, have limited mobility, or need regular physician follow-up.

Your request will be reviewed according to the patient’s health condition, follow-up needs and suitability for physician evaluation, home follow-up or hospital coordination when necessary.

Personal Information

Please enter the basic information required for physician consultation and follow-up contact.

Please enter your phone number with the correct country code. We may contact you via WhatsApp or phone regarding your request.

Example: +90 5XX XXX XX XX or +44 7XXX XXXXXX

Who are you submitting this request for?

Myself

My mother / father

Please indicate why mobile family doctor follow-up is needed so that your request can be evaluated properly.

Why do you need mobile family doctor follow-up?

I have difficulty leaving home / the patient has difficulty leaving home

There is limited mobility

Elderly patient follow-up is needed

Regular follow-up of chronic diseases is needed

I would like recent tests or reports to be reviewed by a physician

I would like a physician consultation before coming to the hospital

I request home medical evaluation / examination

I would like hospital referral and coordination if necessary

What is the main purpose of your request?

Initial physician evaluation

Creating a regular follow-up plan

Follow-up of existing medical conditions

Review of tests / medical reports

Home medical examination request

Hospital referral and coordination

I am not sure, I would like the physician to guide me

Mobility and Home Follow-up Need

This section helps us understand the patient’s ability to leave home, daily support needs and whether home physician evaluation may be appropriate.

What is the patient’s ability to leave home?

Can leave home independently

Can leave home with support

Has significant difficulty leaving home

Usually cannot leave home

Is support needed in daily life?

No support needed

Walking / mobility support is needed

Medication follow-up is needed

Nutrition support is needed

Personal care support is needed

Blood pressure / blood sugar / vital sign monitoring is needed

Wound care or dressing is needed

There is a risk of falling

There is caregiver / companion support

What is your priority expectation from home physician evaluation?

General health assessment

Chronic disease follow-up

Test / medical report review

Blood pressure / blood sugar / general condition monitoring

Mobility and fall risk assessment

Assessment of whether hospital visit is necessary

Creating a regular follow-up plan

Existing Medical Conditions and Medications

Existing medical conditions, medications and recent health events are important before physician evaluation.

Does the patient have any known medical conditions?

No known chronic disease

Cardiovascular disease

Neurological disease / history of stroke

Dementia / Alzheimer’s disease

Walking / balance problem

Are there any regularly used medications?

If available, please write the medication names, doses and frequency of use. If you do not know, you may leave this blank.

Has there been any recent hospital admission or hospitalization?

Yes, within the last week

Yes, within the last month

Yes, within the last 3 months

Urgency and Contact Preference

Please indicate how urgent your request is and how you prefer to be contacted.

How urgent is your request?

Not urgent, I would like information and planning

I would like to be contacted within the next few days

I would like to be contacted today / as soon as possible

I am not sure whether the situation is urgent

How would you prefer to be contacted?

Via WhatsApp

First via WhatsApp, then by phone if necessary

Is there anything else you would like to add?

You may write any additional information about the patient’s condition, special needs, address/transportation details, or anything you would like the physician to know.

Consent and Submission

I have read, understood and agree: This form does not replace emergency medical evaluation; my request will be received as a pre-assessment for mobile family doctor follow-up, and the Kamiloğlu Hospital Health+ team may contact me regarding this request.

For any questions about your form, please contact:

Dr. Pelin Akman

Kamiloğlu Hospital Emergency Department

WhatsApp / Phone: +90 5338428459