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

    Weight in kilograms

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    PART B1 - Symptoms Pain indication (LUMBAR/THORACIC) spine surgery (move down to B2 for CERVICAL)

    Do you have back pain? yesno

    Do you have pain in the left upper leg? yesno

    Do you have pain in the left lower leg? yesno

    Do you have pain in the right upper leg? yesno

    Do you have pain in the right lower leg? yesno

    Is there a loss of strength in one or both legs? yesno

    Pain in right buttock? yesno

    Pain in left buttock? yesno

    Since when have you had pain?

    Which leg hurts the most? leftrightboth the same

    Have you got back pain and leg pain while:

    Lying yesno

    Standing yesno

    Walking behind a shopping cart yesno

    Cycling yesno

    Sitting yesno

    Are there any sensation disorders in your legs? yesno

    When does the pain come up in your leg(s) when walking?
    NotAt homeWhen walking 100-500mWhen walking 500-1000mWhen walking more than 1000m

    Did you undergo lumbar/thoracic spine surgery before? yesno

    Have an MRI lumbar / thoracic spine been done in the past 3 months?

    Lumbar spine yesno

    Thoracic spine yesno

    If yes, please attach the description of result in PDF

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    PART B2 - Symptoms Pain indication (CERVICAL) spine surgery (move up to B1 for LUMBAR/THORACIC)

    Do you have neck pain? yesno

    Do you have pain in the left arm? yesno

    Do you have pain in the left hand? yesno

    Do you have pain in the right arm? yesno

    Do you have pain in the right hand? yesno

    Is there a loss of strength in one or both hands? yesno

    Are there any sensation disorders in arm or hand area? yesno

    Do you have dizziness when moving your neck? yesno

    Did you undergo cervical surgery before? yesno

    Have an MRI cervical spine been done in the past 3 months? yesno

    If yes, please attach the description of result in PDF:

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    Part C - Medical information and history 1/3

    Planned treatment

    Previous spine surgery (and approximately date)

    AIDS / HIV 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 list

    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

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    Part C - Medical information and history 2/3

    Thyroid problems yesno

    If yes, please list:

    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

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    Part C - Medical information and history 3/3

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

    What conditions are you taking the listed medications for?

    Do you suffer from chronic diseases?yesno

    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

    Additional important information about your medical history:

    Approximate date of your arrival

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    Part D - Additional Personal and Contact Data

    Address

    City

    Country

    Preferred contact time

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