LINK4MED

LINK4MED

Patient Medical History Form

Please give us your general information / Opšte informacije

Please fill in your measures / Unesite vaše mere

Please tell us about your family health history/ Unesite podatke o porodičnoj zdravstvenoj istoriji

Diabetes / Dijabetes
Cancer / Rak
Overweight / Prekomerna težina
Obesity / Gojaznost
Heart disease / Srčana oboljenja
High blood pressure / Visok krvni pritisak
Other / Ostalo

Please tell us about your personal health history / Unesite podatke o vašoj zdravstvenoj istoriji

Diabetes / Dijabetes

Cancer / Rak

Heart disease / Srčana oboljenja

Gastric symptoms / Gastrični simptomi

*BMI - Index telesne mase (postoji On-line BMI kalkulator)

Please list any previous surgeries you have had / Navedite sve operacije koje ste ranije imali

Please list any current medications you are taking / Navedite sve lekove koje trenutno koristite

Please list any major illnesses you have had / Navedite sve veće bolesti od kojih ste bolovali

Patient declaration / Izjava pacijenta

I declare that I have truthfully completed this form any have not made any purposeful omissions. / Izjavljujem da sam istinito popunio/la ovaj obrazac i da nisam napravio/la ni jedan nameran propust.

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