PATIENT CONSENT TO PROCESSING PERSONAL DATA

    I hereby provide explicit and unambiguous consent to KCM Clinic S.A. for the processing of my data, as defined in the Act of April 27, 2016, regarding the protection of natural persons about the processing of personal data and the free movement of such data, and repealing Directive 95/46/EC GDPR (General Data Protection Regulation) Regulation (EU) 2016/679 of the European Parliament and the Council.

    YESNO

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    Part A - Basic data

    Sexfemalemale

    Family name

    First name

    Date of birth

    Age

    Phone

    Email

    Height in centimeters

    Current weight in kilograms

    Max weight in kilograms in past

    BMI

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    Part B - Medical information and history 1/3

    Current medication

    Planned treatment

    Previous bariatric surgery (and approximately date)

    Joint diseases yesno

    Spine diseases yesno

    DVT (deep venous thrombosis) yesno

    AIDS / HIV positive yesno

    Hepatitis A,B,C,D,E,G yesno

    Blood Clots yesno

    Bleeding Problems yesno

    High blood pressure yesno

    Breathing problems yesno

    Chest pain / heart attack yesno

    Irregular heartbeat yesno

    Other heart problems, If Yes, please explain

    Cancer yesno

    Stroke yesno

    Epilepsy yesno

    Arthritis yesno

    Anemia yesno

    Asthma yesno

    Diabetes yesno

    Do you use insulin? yesno

    Nose / throat problems yesno

    Kidney problems yesno

    Liver problems yesno

    Stomach problems yesno

    If Yes, please explain?

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    Part B - Medical information and history 2/3

    Have you ever smoked cigarettes?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?

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    Part B - Medical information and history 3/3

    Are you allergic to any medication?yesno

    List all medications to which you are allergic

    If there is an allergy to medicines, please specify to which ones

    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

    What conditions are you taking the listed medications for?

    Do you suffer from chronic diseases?yesno

    Additional important information about your medical history:

    Approximate date of your arrival

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    Part C - Additional Personal and Contact Data

    Address

    City

    Country

    Preferred contact time

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