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) |
|
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Do you have increases or decreases of arterial blood pressure? |
|
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Do you have dizziness, loss of consciousness, dyspnea etc. at introduction of anesthetics and other medicinal preparations? |
|
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Blood diseases |
|
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Liver diseases |
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Renal diseases |
|
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Diabetes |
|
|
Diseases of thyroid, parathyroid gland |
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Epilepsy, other diseases of central and peripheral nervous system |
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Diseases of lungs |
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Skin diseases |
|
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Presence of intervertebral hernias and operations on the spinal column |
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Diseases of skeletal system and joints |
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Have you undergone treatment of other diseases for the last days, weeks, months? |
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Gastro-intestinal tract diseases |
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Pregnancy, lactation period |
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Venereal diseases |
|
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Metal implants, rods, prostheses |
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Are you a donor? |
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Hemotransfusions (when it was carried out) |
|
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Were any injections made for the last 6 months (intramuscular, hypodermic, etc.)? |
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Did you have (or do you have) fungus diseases? |
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Scars, cicatrices, predisposition to development of keloids? |
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Did you have (or or do you have) inexplicable long-lasting fevers |
|
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Long periods of sore throat or difficulties with swallowing |
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Headaches, migraines |
|
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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 ________________________
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.
(signature)
Date _______________________