How Does It Work

If you decide to choose MediCzech, you will get a reliable and professional partner that will provide a complete service and medical treatment in the Czech Republic. We will take care of all matters related to the organisation of your trip and you will be able to focus only on the effectiveness of your treatment. We will also ensure that you will be clearly and accurately informed at every step of the process. You will find instructions on how to proceed below. We welcome your inquiries at any time.

 

Questionnaire




Day:
Evening:





cm
feet
inches
kg
stone
pounds




What kind of operation are you going to have?
What operation(s) have you undergone in the past and in what year?
What type of anaesthesia was used (local – regional - general)? (If known)
Have you suffered from any complications during or after the operations - describe them:
Do you suffer from any local or general anaesthetic problem – describe them:
How was your scarring after the operation? (a thin line, a coloured scar, a raised lump on the skin, or specify if other)


Check YES or NO what is appropriate. If the answer is YES, provide the details.
Have you been or are you being treated for a heart disease?
shortness of breath
chest pain
swelling of legs
heart attack
heart rhythm disorder
Have you been or are you being treated for high blood pressure?
Do you suffer from asthma?
Did you have pulmonary tuberculosis or pneumonia?
Have you been or are you being treated for diabetes mellitus?
diet
tablets
insulin
Are you treated for thyroid gland problems?
Have you had a treatment for renal disease (infections, nephrolithiasis)?
infections
nephrolithiasis
Do you have prostate problems?
Have you had a treatment for hepatic disease (hepatitis, mononucleosis)?
hepatitis
mononucleosis
Do you have a gastric or duodenal ulcer?
Do you have varicose veins, phlebitis (thrombosis, embolisation)?
thrombosis
embolisation
How often do you drink alcohol? Please specify.
Do you have a neurological disease (epilepsy, myasthenia, headaches, paralysis of nerves, condition after stroke, borreliosis, or operation of spinal discs)?
epilepsy
myasthenia
headaches
paralysis of nerves
condition after stroke
borreliosis
operation of spinal disc
Do you have any sleep problems?
Do you consider yourself under stress at present?
Have you ever used hormonal medications (Prednison, Triamcinolon, Cortisone)?
prednison
triamcinolon
Cortisone
Any possibility of pregnancy or are you attempting to get pregnant?
Number of Previous Childbirths:
Caesarean Section (number and year):
Are you taking birth control pills?
Are you being treated for glaucoma?
Have you ever had prolonged bleeding (after a tooth extraction, nose bleeding, after injury)?
after a tooth extraction
nose bleeding
after injury
Have you ever had a blood transfusion?
Have you ever had any screening for cancers?
Bowel Cancer
Male: Prostate Screening
Female: Breast Screening
Female: Cervical Cancer by smear test
Have you ever had treatment in oncology?
Did you lose weight in last year?
How long do you have the same and stable weight?
Did you have radiation treatment?
Did anyone of your blood relatives have complications during or after operation (e.g. unexplained death)?
Do you have any feeling of stiffness around your mouth after drinking coffee?
Do you have any loose teeth or removable dentures or bridges?
Do you smoke, drink alcohol or do you have any other relevant habits (e.g. taking sleeping pills)?
smoke
drink
other relevant habits
If you smoke at present, how many cigarettes a day do you smoke?
If you have stopped smoking – when did you stop? (month, year or both)
If you drink alcohol, how many units do you drink per week? (one unit = half a pint of beer or one small glass of wine, one single measure of spirits)
Are you allergic to something?
Do you have any food allergies?
Do you have any untreated medical problems?
What kind of medications are you using at present?
For weight loss treatment: Visit to psychologist and/or psychiatrist?
Hospitalisation in mental hospital (When, how long, why):
Psychiatric medication (When, how long, for what reason and what type of psychiatric medication.)
Do you suffer from any eating disorder? (Mental bulimia or any other?)
Any history of alcohol/drug abuse?
Do you need any special assistance/care/facilitation for your stay at the clinic?




Are you a vegetarian?
How many portions of fruit do you eat a day?
How many portions of vegetables do you eat a day?
How many times a week do you eat fish?
How many times a week do you eat red meat (beef, lamb, pork)?
How many glasses (250 ml) of water do you drink a day?
Do you regularly play sports or take exercise?

Contact us

phone
0800 011 23 14(free line in the UK)

office hours

MO – FRI: 7 – 17
Fields marked with *
are mandatory