Medical questionnaire
(En)

SURNAME

NAME

DATE OF BIRTH

HOME PHONE

MOBILE PHONE

ADDRESS

POSTAL CODE

CITY

DOCTOR

OCCUPATION

INSURANCE

Yes

IF YES WHICH

Medical History:

What medication are you currently taking?

For what condition?

Do you suffer from allergic reactions? (Asthma, Eczema, Hay Fever ...)

Do you have allergic reactions to certain drugs? If yes, which ones

Are you a smoker? If yes, how many cigarettes per day?

What is your current weight?

Indicate any condition : shortness of breath, chest pain, abnormal bleeding nose or gums), palpitation, muscle cramps, dizziness etc ....

What is your normal blood pressure?

Envoyé !

Erreur serveur

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