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Robotic – General Surgery Questionnaire

For the better understanding of your health problem and in order to design the ideal treatment plan for you, it is important to know as much detail as possible from your medical history.

Please, complete this questionnaire form as accurately as possible.

EN – Ερωτηματολόγιο Γενικής Χειρουργικής















EMERGENCY CONTACT INFORMATION:




WEIGHT HISTORY



CURRENT ILLNESS




PAST MEDICAL HISTORY (PMH)
PEDIATRIC MEDICAL HISTORY




ADULT PATIENT MEDICAL HISTORY

Please, note below any diseases that you suffer from, are being treated for or you have been hospitalized in the past.

Other diseases (please, describe here in detail)

FOR WOMEN





FOR MEN



PAST SURGICAL HISTORY

Describe the type of surgery, date, hospital and outcome – complications




MEDICATIONS

Please, note all medications that you are currently using and their dosages. Do not neglect to mention the medications that are not taken daily but only when symptoms are present.









ALLERGIES





FAMILY HISTORY

Is there a family history with significant medical conditions such as diabetes, heart disease, obesity, cancer, etc.?


Father:


Mother:


Brothers and Sisters:


SOCIAL HISTORY











GASTROINTESTINAL






CARDIOVASCULAR



RESPIRATORY





URINARY




NEUROLOGIC




MENTAL HEALTH





OTHER HISTORY DETAILS & COMMENTS

INFORMED CONSENT INFORMATION