Medical Form

Information

Full Name

First

Surname

Email address*

Phone:*

Date Of Brith*

Address :*

City:*

High :*

Weight:*

Disease to be treated

1-*

2-

3-

4-

5-

Clinical History

Write down your disease history with dates when possible.

Symptoms

Pains

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Cramps

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Pains

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Fatigue

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Pains

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Sensation loss (numbness

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Reduced mobility (Walking difficulty or weakness of leg or feet)

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Speak disturbance (Aphasia)

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Loss of grasped Loss of expressed speach Spoken or written (Expression Aphasia

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

disorder Coordination

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Paralysis

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Heart attack

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

High blood pressure

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Thyroid disease

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Sleeping disorder

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Medications & Drugs

Medications

Dose

Frequency

Do you take any blood thinner like Aspirin or Warfarine? Which ?

Blood thinner

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Do you have allergic reactions against medications or any things else? Which?

Allergical reactions

YES

NO

If the answer is yes, please give an explanation in the box

Short briefing

Operations

Which operations have you done so far

Operation

Year

Other diseases

Do have other diseases you want to mention

Diagnosis

Date of diagnosis

This field should be left blank

Medical History

Information

Disease to be treated

Clinical History

Symptoms

Medications & Drugs

Operations

Other diseases

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