Medical history

Fill in the fields and send off the form by e-mail. You will sign the completed form upon arrival.

The application form is confidential and secured. All the personal data and medical information are confidential and shall be used exclusively for the purpose of treatment and administrative records.

Please fill in all fields marked with *

Title*
First name*
Surname*
Date of birth*
Street*
City*
Post code*
E-mail address
Telephone/fax*
Mobile phone
I consent to my personal data and medical documentation (including examination and X-ray results) being used for the purpose of treatment.

Next of Kin contact details:

Title
First name
Surname
Street*
City*
E-mail address
Telephone/fax
Mobile phone

Do you have or have you ever had	YES	NO	If your answer is "YES",  please specify
Heart disease
Blood vessels disease
High blood pressure (how long)
Myocardial infarction (when)
Shortness of breath and fatigue caused by effort
Swelling of legs, feet or ankles
Bleeding tendency
Allergies (what kind)
Asthma
Lung diseases
Cancer diseases (what kind)
Diabetes (what kind)
Gastric diseases
Kidney diseases
Epilepsy
Neurological diseases
Headaches
Jaundice, liver inflammation (what kind)
HIV1/2 positive/AIDS
Rheumatic diseases
Do you take any drugs?
Do you take any aspirin derivatives or other nonsteroidal anti-inflammatory drugs?
Do you take hormonal contraceptives?
Are you allergic to antibiotics, drugs?
Are  you allergic to anaesthetics?
Pregnancy
Smoking?
Drinking alcohol? (how often)
Any narcotics?
Undergone surgeries
Height *	cm
Weight *	kg
All the information concerning my health condition provided herein is true. I consent to the above information being used for the purpose of treatment.