PATIENT DETAILS







    MEDICAL INFORMATION

    (DO YOU HAVE OR HAVE YOU HAD)

    AIDS/HIV+JaNee

    AnemiaJaNee

    ArthritisJaNee

    AsthmaJaNee

    Back ProblemsJaNee

    Bladder InfectionJaNee

    Bleeding Tend.JaNee

    Blood ClotsJaNee

    BronchitisJaNee

    History of cancerJaNee

    DiabetesJaNee

    High Blood PressureJaNee

    ColitisJaNee

    Congenital HeartJaNee

    EpilepsyJaNee

    Fainting SpellsJaNee

    GoiterJaNee

    Hay FeverJaNee

    HepatitisJaNee

    Kidney DiseaseJaNee

    Liver DiseaseJaNee

    LeukemiaJaNee

    MigraineJaNee

    Nervous BreakdownJaNee

    PneumoniaJaNee

    PalpitationsJaNee

    Pain in the ChestJaNee

    Rheumatic HeartJaNee

    Shortness of breathJaNee

    Stomach UlcersJaNee

    Stroke HistoryJaNee

    Thyroid DiseaseJaNee

    TuberculosisJaNee

    Cold or flu recently?JaNee

    Heart Attack History?

    JaNee

    Do you have any metal implants/devices?

    JaNee


    Do you smoke?

    JaNee

    Drink alcohol?

    JaNee








    PAST SURGERIES & ANAMNESIS



    Bad reactions to anesthesia?

    JaNee

    WOMEN ONLY

    Pregnant?

    JaNee


    Regular periods?

    JaNee



    SLEEP APNEA SYMPTOMS

    Tired upon wakingJaNee

    Trouble staying asleepJaNee

    Told that I snoreJaNee

    Arms/legs jerkJaNee

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    Ayşe Mayda Straat, Nr:15c
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    Mandaryn Grove Gesondheids- en Welstands-oord

    Atatürk-distrik, 2175 Straat, Nr:79
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