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 PARLIAMENT AND OF THE COUNCIL.
    YESNO

    Part A Basic data

    Sexmalefemale

    Family name

    First name

    Date of birth

    Country

    Phone

    Email

    Height in cm

    Weight in kg

    Part B Medical information and history

    Planned treatment

    AIDS/HIV

    yesno

    Hepatitis A,B,C

    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 list

    yesno

    Cancer

    yesno

    Stroke

    yesno

    Epilepsy

    yesno

    Arthritis

    yesno

    Anemia

    yesno

    Asthma

    yesno

    Diabetes

    yesno

    Do you take insulin?

    yesno

    Nose/throat problems

    yesno

    Kidney problems

    yesno

    Liver problems

    yesno

    Stomach problems

    yesno

    Thyroid problems

    yesno

    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

    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

    Part C Additional Personal and Contact Data

    Address info:
    Address
    City
    Country
    Preferred contact time