Questionnaire

  • kotva
    • Contact details
    • Phone:
    • Personal details
    • Height:
      Weight:
    • Medical details

      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?
    • Have you been or are you being treated for diabetes mellitus?
    • Have you had a treatment for renal disease (infections, nephrolithiasis)?
    • Have you had a treatment for hepatic disease (hepatitis, mononucleosis)?
    • Do you have varicose veins, phlebitis (thrombosis, embolisation)?
    • Do you have a neurological disease (epilepsy, myasthenia, headaches, paralysis of nerves, condition after stroke, borreliosis, or operation of spinal discs)?

      If the answer is yes, please specify (snoring, tiredness after awaking, falling asleep during day, apneusis, sleep apnoea):

    • Have you ever used hormonal medications (Prednison, Triamcinolon, Cortisone)?
    • Have you ever had prolonged bleeding (after a tooth extraction, nose bleeding, after injury)?
    • Have you ever had any screening for cancers?
    • Do you smoke, drink alcohol or do you have any other relevant habits (e.g. taking sleeping pills)?
    • Diet, Healthy eating, exercise
    • It is obligatory for our patients to be able to speak and understand one of the following languages: English, German, Czech, Slovak

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