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