Patient Medical History and Consent
Please complete the information.
1. Personal information
First name
Parent's first name
Last name
Date of birth
Address
Contact phone
Gender
Female
Male
Email address
2. Health status
High blood pressure?
Yes
No
Diabetes?
Yes
No
Diabetes type
Type 1
Type 2
Heart disease?
Yes
No
Allergies to medication or food?
Yes
No
Please list allergies
3. Treatments and procedures
Surgery in the last 6 months?
Yes
No
Please provide surgery details
Artificial valves, pacemaker or bypass?
Yes
No
Please provide valve / pacemaker / bypass details
Radiation therapy?
Yes
No
Date of last radiation therapy
Chemotherapy?
Yes
No
Last chemotherapy cycle
Date of last cycle
4. Other conditions
Liver or kidney disease?
Yes
No
Gastritis?
Yes
No
Osteoporosis?
Yes
No
Osteoporosis therapy
Other medical conditions
Have you had an infectious disease? Hep. B, Hep. C, HIV, jaundice?
Yes
No
Please specify infectious disease
Pregnant or breastfeeding?
Yes
No
5. Medication
Medication used daily
Blood thinning medication?
Yes
No
Which blood thinning medication
6. Visit information
How did you hear about our clinic?
Facebook / Instagram / TikTok
Friend recommendation
LinkedIn
Google
Other
Other — please specify
Have you used our emergency services at night or during weekends?
Yes
No
7. Voluntary Patient Consent
The patient has been provided with information about the diagnosis and prognosis, as well as a description, the purpose and benefits of the proposed medical procedure and the possible consequences of undergoing or not undergoing the proposed medical procedure. The patient has consented to the proposed procedure in accordance with Articles 11 and 15 of the Law on Patients' Rights. The patient has been informed about the schedule of regular appointments and the plan of three-month / six-month check-ups, which the patient accepts and which are intended to support the success of the previously provided treatments. The patient consents to photography and recording for the purpose of medical documentation and for use for medical-scientific and educational purposes, including educational purposes on social media.
I agree with the stated terms, data processing and voluntary consent
Patient signature
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