ד"ר דן הרשקוביץ
medical questionnaire
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Hebrew Form
Date
ID Number
Last Name
First Name
medical questionnaire
anemia
dizziness
Arthritis
neurosis
asthma
the thyroid glands
Rheumatic fever
heart defect
epilepsy
AIDS
Hormonal problems
venereal disease
heart disease
Kidney disease
Blood clotting problems
ulcer
diabetes mellitus
Fainting
Sinusitis
Blood Pressure
Liver disease / jaundice
radiation therapy
blood transfusion
Osteoporosis
smoking
pregnancy
hospitalizations
the attending physician
Medicines in regular use
Drug sensitivity / allergy
I confirm that the above is true and undertake to notify the doctor of any change in health status, and or use of medication.
customer's signature
X
C
Choosing a doctor
Manual Signature
ד"ר דן הרשקוביץ
The doctor's name
The doctor's signature
X
C
License number
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Clinic is required.
