Konsultacje lekarskie online i wizyty domowe

Contact questionaire

You can request contact regarding a doctor visit.

This is a fast track contact form with minimal information required.

If a doctor's house call is dispatched a form with further information will be requested regarding the health , medications of the patient.

Name		Last name
e-mail:
Telephone number
NR PESEL (polish number if applicable)
Street and number
City
Postal code
expectations
Please mark any symptoms you are having or had during this illness	Chest pain Short of breath Loss of consciousness runny nose dry cough productive cough sneezing general malaise diarrhoea vomitting pain or burning during urination chills back pain symptoms of sciatica other - specify in field " State any other conditions or symptoms relevant"
Did you feel an increased temperature
What was the highest temperature measurement
Mark any conditions a doctor diagnosed you with	Migraine ( by neurologist ) other headache Arrythmia Asthma Heart failure Kidney failure Liver failure Heart defects Cancer or malignancy Immune system defects or immunosuppresion Aortic aneurysm other arterial aneurysm Deep venous thrombosis Varicose veins
State any other conditions or symptoms relevant
Did you have difficulties in getting a consult at your normal health care provider for example POZ / NFZ ?
Acceptance of processing of personal information as in the information processing document	I hereby accept processing of my personal information
Do you accept the terms of the service?	I hereby understand and accept the terms of the service
Do you confirm the anwsers to all questions?	yes
Additional information.