HEALTH QUESTIONNAIRE

    1. PATIENT DETAILS*
    *mandatory data
    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

    Wrocław

    ul. Powstańców Śląskich 56a/2

    Wskazówki dojazdu

    Pon – Pt: 9:00 – 19:00
    Sob: 10:00-16:00
    (po wcześniejszym uzgodnieniu terminu)

    email: [email protected]

    Rejestracja

    +48 71 70 70 993

    Warszawa

    Ul. Jaktorowska 5/U1

    Wskazówki dojazdu

    Pon – Pt: 10:00 – 20:00
    Sob: 10:00-16:00
    (po wcześniejszym uzgodnieniu terminu)

    email: [email protected]

    Rejestracja

    +48 22 26 60 876
    wsparcie
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