FR

Pre-consultation questionnaire

DO YOU TAKE ANY MEDICATION

SURGERIES :

CHECK YES OR NO / UNDERLINE OR DESCRIBE THE PROBLEM:

MEDICAL CONDITIONS :

1. Drug allergies or other specify
2. Mental illness
3. Infectious diseases (pneumonia, pleurisy, tuberculosis, AIDS, hepatitis)
4. Cardio-vascular diseases (high pressure, heart disease, paralysis)
5. Other

Life style habits :

1. Drugs (LSD, marijuana, hash, etc.)
2. Tobacco (cigarettes, cigars, pipe)
3. Alcohol (beer, hard liquor) if occasionally check no

Do you currently suffer from :

1. Vision disorders, deafness, tinnitus, dizziness, frequent sore throat, voice changes, headache :
2. Cough, shortness of breath, sputuns , dots in the back, hoarseness, asthma, sleep apnea:
3. Palpitations, chest pains, ankle swelling, leg cramps, varicose veins :
4. Difficulty swallowing, heartburn, nausea, vomiting, frequent diarrhea, constipation, blood in the stool, hemorrhoids, black stools:
5. Pain or burning when urinating, urinating often and little at a time:
6. Breasts: pain, bumps, flow, change in skin appearance:
7. Irregular or painful menstruation, vaginal discharge, pregnancy :
8. Abnormal bleeding during cutting or tooth extraction, frequent bruising (blue):