We take responsibility for data entered by You Name (obligatory): Middle name: Surname (obligatory): Address: Home phone: Mobile (obligatory): E-mail (obligatory): Date of birth: ID card #: Sphere of activity: Work type: mental physical Please, describe shortly a painful zone: (For example: 1. Lumbar pain, nape pain, headache, knee pain, etc. 2. Chest pain, abdominal pain, rectal bleeding and etc.) Please, describe basic complaints in own words (Your health problems) Anamnesa: Height: Weight: Sex: M F Smoking: Yes No IF "Yes", how many per day: How many years have you been smoking: If you stopped smoking, how many years you have smoked: Alcohol: Yes No How much per day: Chronic and previous diseases: Eyes deseases or vision problems: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Ear deseases or hearing problems: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Had you dizziness or vertigo? Yes No If "yes", please wrigh the year: Diabetes: Yes No Level og glucose: HbA1C: If "yes", how long have you known about it? since Arterial hypertension: Yes No Level: Systolic: Diastolic: If "yes", how long have you known about it? Since Kidney or urologic diseases: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Creatinine: Urea: Gynecologic diseases?: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Diseases of digestive tract: Yes No Please, wright name disease: Do you suffer from heartburn?: Yes No Constipation?: Yes No Hemorrhoids?: Yes No Diarrhea?: Yes No If "yes", how long have you known about it? Since Ischemic heart disease: Yes No If "yes", how long have you known about it? Since Myocardial infarct: Yes No If "yes", how many times: If "yes", please wrigh the year: Coronary catheterization: Yes No CABG: Yes No If "yes", please wrigh the year: Cerovascular taccident: Yes No If "yes", please wrigh the year: Artery disease: Yes No Vessel diseases: Yes No If "yes", please name disease: Vessels operation: Yes No If "yes", please wrigh the year: Disease of liver: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Lung disease: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Disease of thyroid: Yes No Please, wright name disease: If "yes", how long have you known about it? Since Anemia or other disease of blood: Yes No Do you know reasons?: If "yes", how long have you known about it? Since Oncologic problems Yes No Please, wright name disease: If "yes", how long have you known about it? Since Have you had an operation?: Yes No If "yes', what kind?: If "yes" , indicate the year: Attach File Attach File I agree with patient's right (check your acceptance of and read rights):
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