🥇 Wellness Travels

Patient's survey sheet

Your full name as given in passport (required) *

Your email (required) *

Have you ever had any problems or diseases related to these organ systems?

Heart and vascular system (blood pressure / myocardial infarction / heart failure / angina pectoris, etc.)?

Yes
No

Is your heart rhythm normal?

Yes
No

Respiratory system (pneumonia / chronic bronchitis / pulmonary tuberculosis, etc.)?

Yes
No

Do you have varicose veins?

Yes
No

Have you ever had thrombosis or thromboembolism?

Yes
No

Digestive system (stomach ulcer / inflammation / gastroesophageal reflux disease and others.)?

Yes
No

The urinary system (kidney inflammation / swelling / inflammation of the bladder, etc.)?

Yes
No

Internal secretion system (thyroid, adrenal disease, tumours / diabetes / spleen, etc..)?

Yes
No

Nervous system (epilepsy / stroke / paralysis, etc.)?

Yes
No

Mental system (depression / eating disorder / panic attacks / etc.)?

Yes
No

Do you have acute or chronic infectious diseases (ex: hepatitis, HIV)?

Yes
No

If you answered yes, please provide more details below:

Do bruises occur spontaneously, as if without a cause?

Yes
No

Does bleeding from a cut finger stops shortly after?

Yes
No

Have you had any operations/surgeries before?

Yes
No

What kind of operation(s) were performed and when?

Did you have any complications during the operation or at the post-operative period?

Yes
No

what kind of?

Have you had any general anesthesia (narcose) before?

Yes
No

How did you feel during the operation and at the post-operative period?

Your height in cm (required) *

Your weight in kg (required) *

Your BMI (Body Mass Index)

Are you pregnant (if applicable)?

Yes
No

Do you take contraceptives (if applicable)?

Yes
No

Will the surgery coincide with your menstrual period?

Yes
No

Do you use any medicine?

Yes
No

If the answer was "Yes", what kind of medicine do you take?

Did you use any medicine in last 3 months?

Yes
No

What kind of medicine do you take?

Are you allergic to something?

Yes
No

Please write what are you allergic to:

Are you vegetarian/vegan?

Yes
No

Do you have any loose teeth?

Yes
No

Do you smoke?

Yes
No

How many years do you smoke and how many cigarettes per day you smoke?

(Optional) additional comments:

Patient information form

Patient's survey sheet

Have you ever had any problems or diseases related to these organ systems?

Thank you for your interest.