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HEALTH QUESTIONNAIRE
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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?
Yes
No
Have you been treated in a hospital in the last two years?
Yes
No
Do you have a chronic illness?
Yes
No
Do you take any medications on a permanent basis?
Yes
No
Have you taken any medications in the last 6 months?
Yes
No
Do you have any allergies?
Yes
No
Have you ever been hospitalized??
Yes
No
Do you smoke?
Yes
No
Do you take dietary supplements, herbs etc. (especially St John's wort, nettle, calendula, horsetail)?
Yes
No
Do you have cardiovascular problems: (previous myocardial infarction, coronary heart disease, heart failure, arrhythmia, myocarditis, etc.)
Yes
No
Do you have thyroid disease?
Yes
No
Do you have any blood or clotting problems?
Yes
No
Do you suffer from cancer?
Yes
No
Do you have any of the following infectious diseases listed below?
a)
Hepatitis A
(Infectious javelin A)
Yes
No
b)
Hepatitis B or C
Yes
No
c)
AIDS
Yes
No
d)
Tuberculosis
Yes
No
e)
Venereal diseases
Yes
No
4. ADDITIONAL QUESTIONS FOR WOMEN
I agree to the processing of my personal data for the purpose of registering for an online medical consultation, in accordance with the
Privacy Policy
.
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Wiadomość *