Pre-diagnostic evaluation

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You are *
pacientattendantmarrieddivorcedwidowaloneemployedfreelancerunemployedretired
Monthly income *
Tobacco consumption *
i don't smokelowmediumhigh
Alcohol consumption *
i don't drinklowmediumhigh
Drugs consumption *
i don't take drugslowaveragehigh
Live / work in a toxic environment *
For females: are you at menopause

If you have been diagnosed, please specify disease and treatment that you follow (if applicable), as follows:
History of psychiatric illness (Eg depression, anxiety, panic attacks, etc.)
Treatment
Memory disease
Treatment
Cardiac disease
Treatment
Peripheral Vascular Disease
Treatment
Respiratory disease
Treatment
Metabolic disease
Treatment

Mama traieste
DaNu
Cauza decesului
Tata traieste
DaNu
Cauza decesului
Bunicul matern traieste
DaNu
Cauza decesului
Bunica materna traieste
DaNu
Cauza decesului
Bunicul patern traieste
DaNu
Cauza decesului
Bunica paterna traieste
DaNu
Cauza decesului
Va rugam sa completati in cazul in care ati efectuat in ultimul an:
Examen RMN rezultat
Examen TC(tomografie computerizata) rezultat
Va rugam sa descrieti mai jos principala problema de sanatate cu care va confruntati in prezent.
Cand a aparut
Simptomele care s-au intensificat in ultima perioada
Tratament (daca urmati vreunul)
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