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Patient Health Questionnaire
Kindly complete the following health questionnaire before your scheduled appointment
Form Submission is restricted
Thank you for the completing the patient health questionnaire!
Step
1
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3
Patient Information / Pasiënt Inligting:
Name / Naam:
*
Surname / Van:
*
ID-Number / ID-Nommer:
*
Tel:
*
E-mail / E-pos:
*
Medical History / Mediese Geskiedenis:
Allergies / Allergieë:
Chronic medication / Kroniese medikasie:
Mark if applicable / Merk indien relevant:
Asthma / Asma
Bleeding condition / Bloedingsneiging
Cardiac conditions / Hart toestande
Diabetic / Diabetes
Epilepsy / Epilepsie
Hypertenstion / Hipertensie
Human Immunodeficiency Virus / Menslike Immuniteitsgebrekvirus
Immune medidiated conditions / Immunologiese toestande
Liver conditions / Lewer toestande
Pregnant / Swangerskap
Porphyria / Porforie
Mental health conditions / Geestelikegesondheid toestande
Respiratory conditions / Respiratoriese toestande
Smoking / Rook
Cancer / Kanker
Consent / Toestemming
Consent to storage of personal health information / Toestemming vir die stoor van persoonlike gesondheidsinligting:
*
I agree / Ek gee toestemming
Patient Signature / Pasiënt Handtekening:
*
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021 300 1572
admin@drpetrievdmerwe.co.za
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