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Beauty and relaxation centre
FIRST SPA

 

                                                              Form code according to OKUD         _______________
                                                                                       Institution code according to OKPO _______________
 
                                                                                    Medical documentation
                                                                                       Form № 25/у
                                                                                       Approved by Ministry of Health of the USSR
                                                                                       04.10.80 № 1030

 
CASE REPORT FORM OF CLIENT № __________

 

SURNAME, FIRST NAME, PATRONYMICS
____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Gender: _____________________________________________________________________________________________________

Date of birth: ________________________________________________________________________________________________
                              (Number, month, year)

Phone:
House ___________, office ______________, mobile ____________

Address: ____________________________________________________________________________________________________

____________________________________________________________________________________________________________

Place of work:  _______________________________________________________________________________________________

____________________________________________________________________________________________________________
(name and character of work)

Occupation, position: __________________________________________________________________________________________

____________________________________________________________________________________________________________

Dependant: __________________________________________________________________________________________________

Date of the form completion: _______________________

 

 

 


 

 

 

 


 

 

 

 

 

 

Beauty and relaxation centre
FIRST SPA

I report the following facts about my state of health:

 

Infectious diseases: ___________________________________________________________________________________________

____________________________________________________________________________________________________________
(Hepatitis, tuberculosis, HIV, RW, herpes)
Chronic diseases: _____________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Oncologic diseases: __________________________________________________________________________________________

___________________________________________________________________________________________________________
Endocrinology diseases:
________________________________________________________________
___________________________________________

___________________________________________________________________________________________________________

Gynecologic diseases: ________________________________________________________________________________________

___________________________________________________________________________________________________________
Date of the last mensis. Cycle regularity:
_______________________________
____________________________________________________________________________

___________________________________________________________________________________________________________

Allergic status: ______________________________________________________________________________________________

___________________________________________________________________________________________________________

Operations performed earlier, traumas:
______________________________
_____________________________________________________________________________

___________________________________________________________________________________________________________

Medicines, drugs taken at present:
(Aspirin, barbiturates, hormonal drugs, vitamins)
___________________________________________________________________________________________________________

Contraindications against the following drugs:
__________________________
_________________________________________________________________________________

Last injection procedures:
__________________________________________
_________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Pain threshold: ______________________________________________________________________________________________








 

I report the following facts about my state of health:
(mark YES or NO in the list of diseases specified below)

 DISEASES

 YES

 NO

Allergic reactions to medicines, other drugs, food products

 

 

Heart diseases

 

 

Vessel diseases (thrombosis, phlebitis, varicosity)

 

 

Do you have increases or decreases of arterial blood pressure?

 

 

Do you have dizziness, loss of consciousness, dyspnea etc. at introduction of anesthetics and other medicinal preparations?

 

 

Blood diseases

 

 

Liver diseases

 

 

Renal diseases

 

 

Diabetes

 

 

Diseases of thyroid, parathyroid gland

 

 

Epilepsy, other diseases of central and peripheral nervous system

 

 

Diseases of lungs

 

 

Skin diseases

 

 

Presence of intervertebral hernias and operations on the spinal column

 

 

Diseases of skeletal system  and joints

 

 

Have you undergone treatment of other diseases for the last days, weeks, months?

 

 

Gastro-intestinal tract diseases

 

 

Pregnancy, lactation period

 

 

Venereal diseases

 

 

Metal implants, rods, prostheses

 

 

Are you a donor?

 

 

Hemotransfusions (when it was carried out)

 

 

Were any injections made for the last 6 months (intramuscular, hypodermic, etc.)?

 

 

Did you have (or do you have) fungus diseases?

 

 

Scars, cicatrices, predisposition to development of keloids?

 

 

Did you have (or or do you have) inexplicable long-lasting fevers

 

 

Long periods of sore throat or difficulties with swallowing

 

 

Headaches, migraines

 

 

Have you noticed weight loss for the last 6 months?

 

 

 

Hereby I testify reliability of the information given by me, and I am warned, that in case of my not informing or inadequate informing «FIRST SPA», the latter does not bear responsibility for the harm done to me thereof.

 

Client ________________________

                (Signature)

Date ________________________

 

 

 

 

 

 

 


 

 

 

 

 

 


 Beauty and relaxation Centre
FIRST SPA

 

Visit purpose: ________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Examination or objective status:

height _____________,  weight ______________,  BP _____________,  pulse _____________

____________________________________________________________________________________________________________

Consultations of experts: _______________________________________________________________________________________

____________________________________________________________________________________________________________

Prescriptions:_________________________________________________________________________________________________

Contraindications: _____________________________________________________________________________________________

_____________________________________________________________________________________________________________

 

I undertake to inform «FIRST SPA» further about all changes of my state of health, I am warned that in case of my not informing or inadequate informing «FIRST SPA», the latter does not bear responsibility for the harm done to me thereof.

 

Client ________________________

                 (signature)

 Date _______________________