Surgeon, Chief physician, Proctologist
Surgeon
Gender * ManWoman
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.
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