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Medical History Form
PERSONAL INFORMATION
Last Name *
First Name *
Date of Birth *
Occupation
Social Security Number *
CONTACT INFORMATION
Address
Phone
Email
PERSONAL MEDICAL HISTORY
Respiratory diseases
Asthma
Pneumonia
COPD (Chronic Obstructive Pulmonary Disease)
Cardiovascular diseases
Hypertension
Heart attack
Date
Angina
Asthma
Stroke
Date
Valvular heart disease
Heart failure
Blood Diseases
Anemia
Haemophilia
Leukemia
Thalassemia
Stigma
Infectious Diseases
Tuberculosis
Rheumatic Fever
Hepatitis
A
B
C
Venereal Diseases
AIDS
Infectious Mononucleosis
Metabolic Diseases
Diabetes mellitus
Hyperthyroidism
Hypothyroidism
Hashimoto's thyroiditis
Allergies
Penicillin
Local anesthetics
Dermatitis
Latex
Other medications / Other
Other allergies
Other diseases
Osteoporosis
Rheumatoid Arthritis
Gastritis
Ulcer
Epilepsy
Nephropathy
Neoplasm
Neuropsychiatric disorders
Other
Other diseases
Taking medication
Yes
No
Drugs
Smoking
Yes
No
Cigarettes per day
Date started smoking
Pregnancy
Yes
No
Trimester of Pregnancy
Radiotherapy
Yes
No
Radiotherapy area
Fainting tendencies
Yes
No
Hospitalization / Surgery
Yes
No
Hospitalization / Surgeries
FAMILY MEDICAL HISTORY (FIRST DEGREE)
Diabetes Mellitus
Yes
No
Hypertension
Yes
No
Hemophilia
Yes
No
Cardiopathy
Yes
No
Malignancy
Yes
No
Tuberculosis
Yes
No
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38 Moatsou, 74132 Rethymno
(+30) 28310 53197
(+30) 693 22 55 445
magda.zisimopoulou@gmail.com
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