HEALTH QUESTIONNAIRE

1. PATIENT DETAILS*
2. QUESTIONNAIRE
The information you will provide is confidential and is important to ensure your safety. Please answer the following questions carefully and honestly. If you have any difficulties with answering any of the questions below please leave it blank and ask the physician for help. The following information is collected to help us to choose the right treatment and an appropriate type of anesthesia for you before surgery.
3. GENERAL QUESTIONS
Are you generally in good health?
YesNo
Have you been treated in a hospital in the last two years?
YesNo
Are you chronically ill?
YesNo
Do you take any medications on a permanent basis?
YesNo
Have you taken any medications in the last 6 months?
YesNo
Are you allergic to anything?
YesNo
Have you ever been hospitalized??
YesNo
Do you smoke?
YesNo
Do you take dietary supplements, herbs etc. (especially St John's wort, nettle, calendula, horsetail)?
YesNo
Do you have cardiovascular problems: (previous myocardial infarction, coronary heart disease, heart failure, arrhythmia, myocarditis, etc.)
YesNo
Do you have thyroid disease?
YesNo
Do you have any blood or clotting problems?
YesNo
Do you suffer from cancer?
YesNo
Do you have any of the following infectious diseases listed below?

a) Hepatitis A (Infectious javelin A)
YesNo
b) Hepatitis B or C
YesNo
c) AIDS
YesNo
d) Tuberculosis
YesNo
e) Venereal diseases
YesNo
4. ADDITIONAL QUESTIONS FOR WOMEN
wsparcie
Zostaw wiadomość. Odpowiemy tak szybko jak to możliwe.
Przepraszamy, obecnie jesteśmy niedostępni. Zostaw wiadomość, odpowiemy najszybciej jak to możliwe.
Przedstaw się *
Wiadomość *