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Anamnes

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Current diseases or diseases in your past:	Yes/No		Medicine/dosage
Cardiac infraction in the past:	Yes	No
Rhythm and conduction disorders:	Yes	No
Coronary disease :	Yes	No
Hypertension:	Yes	No
Other cardiovascular system diseases:	Yes	No
Pneumonia or bronchitis:	Yes	No
Bronchial asthma :	Yes	No
Other pulmonary diseases:	Yes	No
Cerebrovascular accident :	Yes	No
Paresis or palsy:	Yes	No
Other nervous system diseases:	Yes	No
Kidney failure :	Yes	No
Other kidney diseases:	Yes	No
Diabetes:	Yes	No
Allergy:	Yes	No
Glaucoma:	Yes	No
Infectious virus hepatitis:	Yes	No
Other liver diseases:	Yes	No
Gastric ulcer :	Yes	No
Blood diseases :	Yes	No
Thyroid gland diseases:	Yes	No
Other hormonal disorders:	Yes	No
Bone structure diseases:	Yes	No
Mental diseases :	Yes	No
Other diseases:	Yes	No

Other questions :

Do your wounds look normal after healing?	Yes No
Have you had any complication with general anaesthesia?	Yes	No
Drug allergies (please specify)?	Yes	No
Do you smoke?	Yes No
If yes, how many?
Do you drink alcohol?	Yes No
If yes, how much?
Number of children?
Pregnancy since:
Other information :

*) Obligatory fields:

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