DR BEATRICE MAGROU

8 Route de Carcassonne 11300 Limoux

+33 4 68 31 25 98

beatrice.magrou@wanadoo.fr

+33 4 68 31 25 98

Health Statement Form

MRS/MR *

MRS

Name*

First name*

Date of birth*

Adress

Physician

Name

Phone number*

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

2- DIzzy spells

3- Allergy (latex ? Antibiotics ? Aspirin ?)

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

5- Blood

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

Votre cabinet est en congé annuel du vendredi 22 juillet au lundi 1 er août et du samedi 6 août au dimanche 21 août.

A bientôt !