Spine Surgery

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

Sexmalefemale

Family name

First name

Date of birth

Country

Phone

Email

Height

Weight

Since when have you had pain?

Which leg hurts the most? leftrightboth the same

Have you got back pain and leg pain while:

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?

If yes, please attach the description of result in PDF

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

Planned treatment

Previous spine surgery (and approximately date)

if yes please list:

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):

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

Address info:
Address
City
Country
Preferred contact time