Questionnaire on the state of health of the patient

01I suffer from Epilepsy  Yes No

02I have a high blood pressure  Yes No

03I have had  Reumatic Fever Bacterial Endocarditic Myocardialinfarct

04 I have implanted  Artificial Valves Pace Maker Artificial hip / knee

05 I bleed a long time after skin cuts, tooth extractions or surgery  Yes No

06I suffer from :  Hemophilia Thrombocytopenia Von Willebrand Leukemia

07I suffer from excessive blood clotting:  Yes No

08 I suffer from Bronchial Asthma  Yes No

09 I I have had  Lung Tuberculosis Tuberculosis of other organs

10I suffer from Ulcer  In stomach Duodenum 12

11I have had Hepatitis:  Yes No

12 I suffer from:  Diabetes Adison’s Disease Hyperthyreosis (Hyperthyroidism)

13I suffer from AIDS  Yes No

14I have had:  Herpes Simplex Herpes zoster Virus Infection

15I am allergic to:  Medicaments Food Other

16I suffer from the illnesses not stated in the questionnaire

17Momentarily I am taking the following medicaments:

18How many cigarettes you smoke per day?

19 I drink alcohol daily  Yes No

20I am taking narcotic drugs  Yes No