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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