Medical history

Operation:___________________________________________________________

Hospitalization: _______________________________________________________

Serious illnesses:______________________________________________________

Serious injuries: ______________________________________________________

Do you smoke? _______________________________________________________

How much? __________________________________________________________

How long? ___________________________________________________________

Do you drink alcohol? __________________________________________________

How much? __________________________________________________________

How long?

Are you taking medicines or drugs? _______________________________________

Which: ______________________________________________________________

Have you ever had the following illnesses? _________________________________

Hepatitis: ___________________________________________________________

Flu: ________________________________________________________________

Liver diseases: ________________________________________________________

Dental caries: ________________________________________________________

Asthma: _____________________________________________________________

Diabetes: ____________________________________________________________
 Marital status

Are you

Single: ______________________________________________________________

Married: ____________________________________________________________

Free relationship: _____________________________________________________

Divorce: _____________________________________________________________

Widower: ___________________________________________________________

Emergency contact

Occupation: _________________________________________________________

Place of work: ________________________________________________________

Employer's name: _____________________________________________________

Phone at work: _______________________________________________________

Familiar: ____________________________________________________________

Address: ____________________________________________________________

Familiar's telephone number: ___________________________________________

 Medical examination

Name: ______________________________________________________________

Last name: __________________________________________________________

Address: ____________________________________________________________

Phone number: _______________________________________________________

Date of birth: ________________________________________________________

Place of birth: ________________________________________________________

Height: _____________________________________________________________

Weight: _____________________________________________________________

Ethnic group: ________________________________________________________

Social security: _______________________________________________________

Medical/Health insurance: ______________________________________________

Policy: ______________________________________________________________