PATIENT CONSENT TO PROCESSING PERSONAL DATA

    I hereby give specific, unambiguous consent to KCM Clinic S.A. for processing my personal data as defined in the Act of April 27 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing, Directive 95/46/EC GDPR (General Data Protection Regulation) Regulation (EU) 2016/679 of the European Parlament and of the council.
    YESNO

    Part A Basic data

    Sexmalefemale

    Family name

    First name

    Date of birth

    Country

    Phone

    Email

    Height in cm

    Current weight in kg

    Max weight in kg in past

    BMI

    Part B Medical information and history

    Current medication

    Planned treatment

    Previous bariatric surgery (and approximately date)

    Joint diseasesyesno

    Spine diseasesyesno

    DVT (deep venous thrombosis)yesno

    AIDS/HIV positiveyesno

    Hepatitis A,B,Cyesno

    Blood Clotsyesno

    Bleeding Problemsyesno

    High blood pressureyesno

    Breathing problemsyesno

    Chest pain / heart attackyesno

    Irregular heartbeatyesno

    Other heart problems, If Yes, please explain

    Canceryesno

    Strokeyesno

    Epilepsyyesno

    Arthritisyesno

    Anemiayesno

    Asthmayesno

    Diabetesyesno

    Do you use insulin?yesno

    Nose/throat problemsyesno

    Kidney problemsyesno

    Liver problemsyesno

    Stomach problemsyesno

    If Yes, please explain?

    Thyroid problemsyesno

    If Yes, please explain?

    Have you ever smoked tobacco?yesno

    How much do you smoke now?

    Within the past 18 months have you been hospitalized, had surgery or received medical care for anything including inpatient or out-patient, ambulatory surgery or delivery of a pregnancy? What reason? *

    Date:

    Please list all your past surgeries (with approximate dates):

    Do you have any implants, screws or metal objects in your body such as pacemaker?yesno

    What is your average blood pressure

    Are you allergic to any medication?yesno

    Do you take an anticoagulant such as Coumadin®, Heparin ®, Acenocoumarol, Clopidogrel, Xarelto, Pradaxa, or a daily aspirin? If yes, when was your last dose?

    List all Medications you currently take with the dosage

    Additional important information about your medical history:

    Approximate date of your arrival

    Part C Additional Personal and Contact Data

    Address info:
    Address
    City
    Country
    Preferred contact time