Contact - Aiwaclinic

DO YOU HAVE ANY CHRONIC OR ACUTE DISEASES ESPECIALLY ANY CONNECTED WITH BEING OVERWEIGHT?
NoYes

ARTERIAL HYPERTENSION (ELEVATED BLOOD PRESSURE)
NoYes

ANY FORM OF ARTHITIS
NoYes

DIABETS
NoYes

GASTRO OESOPHAGEAL REFLUX SYNDROME (HEARTBURN / FREQUENT BELCHING)
NoYes

HYPERCHOLESTEROLAEMIA
NoYes

VENOUS INSUFFICIENCY
NoYes

CHRONIC GASTRITIS
NoYes

GASTRIC OR DUODENAL ULCER

DISEASE CONNECTED WITH ONCOLOGY
NoYes

DO YOU HAVE NOW OR DID YOU HAVE IN THE PAST ANY PSYCHIATRIC DISEASE?

HAVE YOU EVER HAD ANY SURGICAL PROCEDURES? IF YES WHAT PROCEDURES?

DO YOU HAVE ANY ALLERGIES?

DO YOU HAVE AN ALLERGY TO ANY MEDICATION? IF YES WHAT REACTION HAVE YOU HAD IN THE PAST?

DO YOU USE ANY MEDICATIONS ON A REGULAR BASIS? IF YES WHAT KIND?

ARE YOU CURRENTLY ON ANY BLOOD THINNING MEDICATIONS?
NoYes

HAVE YOU EVER HAD A BLOOD TRANSFUSION?
NoYes

ANY OTHER INFORMATION THAT YOU THINK MAY BE RELEVANT.

Aiwa Clinic in Riga, Latvia