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Date of filling: 26.10.2021 17:29:33 (appears automatically)

Gender

Please read the following document:

Patient questionnaire (covid-19)

1. Have you been in isolation or self-isolation for the last 14 days before visiting the clinic?

2. Were there any close contacts over the past 14 days with a person under the supervision due to COVID-19, who subsequently become ill?

3. Were there any close contacts over the past 14 days with a person who was diagnosed with a laboratory confirmed COVID-19?

4. Have you visited a clinic or medical centre where patients are tested for COVID-19?

5. Have you experienced one or more symptoms in the last 14 days?

6. Have you tested for COVID-19?

Result of the last testing


Health questionnaire

2. Allergy (medications, food, others)?

How is it manifested?

3. Blood type:

резус-фактор:

4. Do you suffer from diseases listed below?

Do you suffer from:
high blood pressure

low blood pressure

6. Do you suffer from seizures, fainting, dizziness

7. Prolonged bleeding after cuts

8. Diabetes

9. Do you take any medications

10. Did you have a head injury

11. Hepatitis A (Botkin's disease)

Hepatitis B, C

12. AIDS, sexually transmitted diseases

13. Periodically occurring oral ulcers, herpes

14. Bruxism (night teeth gnashing)

15. Sinus maxillary disease

16. Do you use addictive drugs

17. Do you smoke

18. For women: Pregnancy


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