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

    Weight

    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:

    -Lyingyesno

    -Standingyesno

    -Walking behind a shopping cartyesno

    -Cyclingyesno

    -Sittingyesno

    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 spineyesno

    If yes, please attach the description of result in PDF

    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

    Planned treatment

    Previous spine surgery (and approximately date)

    AIDS/HIV yesno

    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 listyesno

    Canceryesno

    Strokeyesno

    Epilepsyyesno

    Arthritisyesno

    Anemiayesno

    Asthmayesno

    Diabetesyesno

    Do you take insulin?yesno

    Nose/throat problemsyesno

    Kidney problemsyesno

    Liver problemsyesno

    Stomach problemsyesno

    Thyroid problemsyesno

    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 D Additional Personal and Contact Data

    Address info:
    Address
    City
    Country
    Preferred contact time