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Eira Hospital
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09 1620 570
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09 1620 570
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09 1620 200
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Name
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Identity number
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Age
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Height
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Weight
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E-mail
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Allergy to medicines, materials (e.g. latex) or soy
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Yes
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Do you have regular medication?
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Have you had surgery and narcosis/anaesthesia?
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Have you experienced side-effects due to anaesthesia?
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Yes
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Are you able to walk non-stop more than three floors of stairs?
No
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Are you able to walk one km without stopping?
No
Yes
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Omegas, fish-oils and other natural products
No
Yes
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Antithrombosis medication (e.g. Asperin, Disperin, Primaspan, Marevan)
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Do you have or have you had any of the following conditions?
Elevated blood pressure
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Yes
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Heart disease
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Arrhythmia
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Lung disease
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Venous thrombosis / cerebrovascular disorder
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Clotting/bleeding disease
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Gastrointestinal Disease
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Liver/renal disease
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Diabetes
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Thyreoid disease
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Neurological disease
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Rheumatil disease
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Malignant tumour
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Mental disorder
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MRSA / infectious disease
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Other illness, e.g. sleep apnea, skin disease
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Do you have document in writing from your blood type?
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Pin tooth / bridge / prsthesis?
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Artificial joints / valve / pacemaker / implant / endoprosthesis / other?
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Do you smoke / use snus / other nicotine products?
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Do you drink alcohol over 10 doses per week?
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Are you pregnant?
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Do you have a special diet?
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Have you been in hospital care within last year domestic or abroad?
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Have you had corona disease?
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Have you been vaccinated against COVID-19?
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