1/4 Dear Madam/Sir, In order to find out more about your health

Dear Madam/Sir,
In order to find out more about your health status we would like to kindly ask you to fill in the
present form and send it back to us by e-mail to: [email protected]
Name
Surname
Date of birth
tel. (optional):
E-mail (optional):
Address (optional):
Sex:
Male
Female
Weight (kg)
Height (cm)
Have you ever suffered
from:
1
2
3
4
YES
NO
Please describe:
cranial injury
uraz czaszki
faintness
omdlenia
epilepsy
padaczka
other diseases of the
nervous system
inne choroby układu nerwowego
5
6
7
8
9
mental health problems
choroby psychiczne
diabetes
cukrzyca
ear diseases
choroby narządu słuchu
eye diseases
choroby narządu wzroku
cardiovascular disease
choroby układu krwionośnego
10 hematologic diseases
choroby układu krwiotwórczego
Initial Interview
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circulatory system
11 diseases
choroby układu krążenia
12 respiratory diseases
choroby układu oddechowego
diseases of the digestive
13 system
choroby układu pokarmowego
14 urinary tract diseases
choroby układu moczowego
musculoskeletal system
15 diseases
choroby układu ruchu
allergies (allergic rhinitis,
16 allergies to drugs, foods,
chemicals, pollen etc.)
uczulenia
17 other health problems
inne problemy zdrowotne
18 Do you smoke?
YES
Czy palisz papierosy?
How would you rate your
19 health condition?
Jak oceniasz swój stan zdrowia?
NO
For how many years? …………………………………………
How many cigarettes per day? …………………………..
Good
Rather good
Relatively weak
Very weak
Other ……………………………………………………………………………………..
PLEASE ANSWER THE FOLLOWING QUESTIONS:
YES NO
Please comment:
Do you play any kind of sports
professionally or
amateurishly? Please describe
the kind of sport and the
frequency of training.
Can you easily climb the stairs
to the second floor or run to
the bus?
Czy możesz wejść bez odpoczynku na II
piętro, podbiec do autobusu
Have you ever had any
operation? What kind? When?
Czy przebyłeś zabiegi operacyjne? Jakie?
Kiedy?
Initial Interview
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Were there any complications
associated with surgery or
anesthesia?
Czy wystąpiły powikłania związane z
operacją? Znieczuleniem?
Are you under the care of a
specialist clinic? What kind?
Czy jesteś pod opieką poradni
specjalistycznej? Jakiej?
Have you been vaccinated
against hepatitis? (type B
jaundice)
Czy byłeś szczepiony przeciwko WZW typu
B?
Do you take any medications?
Please specify.
Czy przyjmujesz leki? Jakie?
Have you ever been
hospitalized? Please specify.
Hospitalizacje
Do you take any hormonal
medications? (i.e.
contraceptives)
Przyjmowane leki hormonalne
Question to women: have you
ever been pregnant? How
many times?
Czy byłaś w ciąży? Ile razy?
What do you expect after the
operation?
Czego oczekujesz po operacji?
When do you feel pain?
Kiedy odczuwasz ból?
I want to be able to continue to play sports actively
I want to walk without any help
I no longer want to feel the pain
Other ……………………………………………………………………………………..
I feel pain only when I do sports
I feel pain when I walk
I feel constant pain, even at rest
I don’t feel any pain
Other……………………………………………………………………..
Question to women: when
was your last menstruation?
Data ostatniej miesiączki
Question to women: when
did you last visited the
gynecologist?
Termin ostatniej wizyty u ginekologa
PLEASE ANSWER QUESTIONS ABOUT YOUR STAY AT THE HOSPITAL
What kind of room would you
like to stay in?
W jakim pokoju chciałbyś mieszkać?
Initial Interview
Single
Double
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Do you have any special diet
preferences?
Czy masz specjalne preferencje
żywieniowe?
None
Vegetarian
Vegan
High protein diet
Halal
Kosher
Other ……………………………………………………………………………………..
How long do you suffer? Jak długo odczuwa Pan/Pani ból?
What are the symptoms? Jakie są objawy?
What kind of pain you feel? Jaki to rodzaj bólu?
Thank you. Please send this form by e-mail to: [email protected]
Initial Interview
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