MEDICAL FORM

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Name of patient
File number
folder
First name of patient
Sex
Telephone
phone
Email
mail
Adress
Town
Postal Code
Birth date
date_range
Occupation
Assurance maladie card number
payment
Expiration date
date_range
Family physician name
Dentist name
Weight
Name, adress and telephone number pharmacy

Please answer all questions

Have you ever taken the following medications :
Are you actually taking other medication or natural products ?
Join a list of medication
0 /
In the eventuallity of a surgery in the opereting room at the hospital, is there any question/preoccupation you would like to discuss with the anestheologist prior to the surgery ?

Have you been or are you actually treated for one or many of these conditions :

Cardiologic problem :
If heart attack, indicate date
date_range
If cardiac malformation, indicate type
If cardiac stent/bipass, indicate date
date_range

Bleeding disorder :

Infection problem :

Endocrinologic problem :

Hepatologic/digestive problem :

Neurologic problem :
If mental health problem, indicate diagnostic :

Oncologic problem :
If cancer, indicate type :
If radiotherapy, indicate :

Pulmonary problem :

Renal problem :

Other problems
If pregnant, how many weeks :
Other medical condition :
Past surgeries :

Are you allergic to :
Other allergies :

Are you using :

Habits
RegularlyOccasionnelyNever
Tabacco
Alcohol
Drugs
If yes, nbr/day

Do you fear dental treatment ?
Patient signature
Date
date_range
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