Medical Second Opinion Request Form

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:
Date of birth (dd.mm.yyyy):
Country:
Profession:
Present Medical Problems:
Please list any known medical problems that you have at present
Medical Problem Date of Onset
Current Medications:
PRESENT ILLNESS
Please list all medications that you are taking currently (antibiotics, antihypertensive drugs,
chemotherapy medicines, blood thinners etc.)
Medicine Name Dosage Date Started
Reason for Application:
MEDIC CENTER - Reprezentantul Oficial pentru Romania al ANADOLU MEDICAL CENTER, Istanbul
Adresa: str. Timisana, nr. 34, cladirea BRD - Groupe Socit Gnrale, cod 900572, CONSTANTA, ROMANIA
tel.: 004.0241.543.920, 004.0241.543.930, fax: 004.0341.432.724
e-mail: [email protected]
http://www.anadolu-medical-center.ro
Please list in chronological order the illnesses or surgeries (if any) you have had as a child or adult.
Illness Year Surgery/Treatment Done
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
tel.: 004.0241.543.920, 004.0241.543.930, fax: 004.0341.432.724
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 Yes No Dont Know If yes, please indicate since when

1. Unexplained weight loss?
2. Fatigue?
3. Change in appetite?
4. Night sweats?
5. Fever or chills?
6. Any type of cancer?
Heart / Vascular Yes No Dont Know If yes, please indicate since when
1. Chest pain/pressure
2. Heart attack
3. Rapid/irregular heart
REVIEW OF SYSTEMS
beats?
4. Fainting?
5. High blood pressure?
6. Any type of cancer?
Eyes Yes No Dont Know If yes, please indicate since when

1. Double vision?
2. Glaucoma?
3. Cataracts?
Ear Nose And Throat Yes No Dont Know If yes, please indicate since when
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?
tel.: 004.0241.543.920, 004.0241.543.930, fax: 004.0341.432.724
Bone And Joint Yes No Dont Know If yes, please indicate since when
1. Chronic joint and muscle
pain?
2. Low back pain?
3. Swollen joints?
Endocrine Yes No Dont Know If yes, please indicate since when

1. Thyroid disease?
2. High blood sugar-
Diabetes?
Pulmonary Yes No Dont Know If yes, please indicate since when

1. Chronic cough?
2. Wheezing?
3. Asthma?
4. Tuberculosis?
5. Bronchitis?
6. Pneumonia?
7. Coughed up blood?
REVIEW OF SYSTEMS
8. Shortness of breath?
Gastrointestinal Yes No Dont Know If yes, please indicate since when

1. Frequent heartburn?
2. Abdominal pain?
3. Vomited blood?
4. Jaundice?
5. Diarrhea?
6. Constipation?
Neurology Yes No Dont Know If yes, please indicate since when

1. Loss of consciousness
2. Vertigo?
3. Memory problems?
4. Seizures or epilepsy?
5. Headache?
6. Numbness of arms, legs,
fingers, toes, face?
Hematology Yes No Dont Know If yes, please indicate since when

1. Anemia ?
2. Bleeding disorder?
3. Enlarged lymph nodes?
tel.: 004.0241.543.920, 004.0241.543.930, fax: 004.0341.432.724
Dermatology Yes No Dont Know If yes, please indicate since when

1. Skin rash?
2. Skin sores that wont heal?
3. Shingles/ herpes?
4. Unusual moles?
5. Mouth sores that wont
heal?
6. Other?
Urology Yes No Dont Know If yes, please indicate since when

1. Blood in urine ?
2. Burning or pain while
urinating?
3. Kidney stones?
4. Difficulty urinating
Other notes, questions and requests:

REVIEW OF SYSTEMS
Thank you for your time and patience in completing this questionnaire.
tel.: 004.0241.543.920, 004.0241.543.930, fax: 004.0341.432.724

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ANADOLU MEDICAL CENTER

MEDICAL DEPARTMENT OF INTERNATIONAL SERVICES

Date of birth (dd.mm.yyyy):

Present Medical Problems:

Medical Problem Date of Onset

Medicine Name Dosage Date Started

Reason for Application:

Illness Year Surgery/Treatment Done

Please indicate the radiological examinations performed in chronological order.

Type Of Radiological Examination Year Result

Other examinations or interventions:

Please indicate pathology results if any:

Type Of Pathological Examination Date Result

Medicine Name Dosage Date Started

Please list radiotherapy dosages if any.

Radiotherapy Dosage Date Started Date Ended

Do you smoke? Please indicate as Yes or No: Yes No

General Yes No Dont Know If yes, please indicate since when

Eyes Yes No Dont Know If yes, please indicate since when

Endocrine Yes No Dont Know If yes, please indicate since when

Pulmonary Yes No Dont Know If yes, please indicate since when

Gastrointestinal Yes No Dont Know If yes, please indicate since when

Neurology Yes No Dont Know If yes, please indicate since when

Hematology Yes No Dont Know If yes, please indicate since when

Dermatology Yes No Dont Know If yes, please indicate since when

Urology Yes No Dont Know If yes, please indicate since when

Other notes, questions and requests:

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