Dossier médical Ang

Personal informations

Requested procedures

Have you ever consulted a doctor for this/these procedure(s)?

Medical information

Do you smoke?
Have you quit smoking?
Do you drink alcohol?

Medical background

Are you currently under medical treatment?
Are you allergic to any medications ?
Do you have other allergies?
Do you suffer from high blood pressure?
Do you suffer from diabetes?
Are you anaemic?
Do you suffer from cholesterol?
Have you ever had phlebitis?
Do you have a cardiovascular disease
Do you suffer from depression?
Do you have a viral illness, cancer, AIDS or other serious diseases?

Surgical history

Have you ever had any surgery?
Have you had problems following anaesthesia
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