Health Statement Form

Sélectionner un praticien * :

MRS/MR

MRS

MR

Name

First name

Date of birth

Adress

Physician

Name

Phone number

Do you have, or did you have any of the following during the past 5 years ? IF YES, please, give details...

1- Consulted or been treated by any Physician or other Medical Practitioner for any disease pertaining to :

Brain or nervous system

Lungs or respiratory tract (asthma, sinusitis...)

Heart or blood vessels (pacemaker, infactions, heart valve, pericarditis...)

stomach or any abdominal organ (stomach ulceres, diabetes, kidney...)

any viral infection (hepatitis A B C, AIDS virus (test for antibody to AIDS Virus ?), herpes)

2- DIzzy spells

3- Allergy (latex ? Antibiotics ? Aspirin ?)

Xray, electrocardiogram (EEG), blood analysis or other diagnostic test ?

6- Any accident, injury, surgical operation, hospital confinement, medical advise or examination other than those mentioned above ?

7- Do you smoke ? If yes, number of cigarets/day

8- FOR FEMALE ONLY : Are you pregnant ? (if pregnant, state how many months :

Do you take medecines ?

If yes give details :

I hereby declare and agree that all the statements and answers contained herein are true, complete and correct to the best of my knowledge. SIGNATURE