Konsultacje lekarskie online i wizyty domowe

Health questionaire

You can request contact regarding a doctor visit. State all the necessary details below and any other information you believe is important.
If a doctor's house call is dispatched 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
medication you normally are on
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
( women ) Are you pregnant ?
( women ) Are you breast feeding ?
( women ) Are you planning to be pregnant in the following weeks ?
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. I also understand the the doctor may deny the sick note in certain cases, such as repeated sick note requests without physical confirmation of symptoms. In case of first denial there is no charge, however in next denial, the money is returned minus administration fee of 29 zł.
Do you confirm the anwsers to all questions?	yes
Additional information.