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Initial consultation

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: 
 


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