MR-Helkropp + Hjärtundersökning - EN Steg 1 av 7 14% Health Form Please note that your examination can only be booked after you have filled in and submitted this form.E-mail Address* Name* First name Surname Personnummer (Swedish Social Security number)*Phone (mobile)*What is your main occupation?*EmployeeBusiness OwnerPensionerOn sick leaveDescribe your main occupation?* Diseases Do you have, or have had, any of the following diseases (only tick the options that are relevant to you)?High blood pressure with tablet treatment*YesNoCardiovascular disease Myocardial infarction Heart failure Angina pectoris Atrial fibrillation Stroke Blood clot requiring blood-thinning medication Diabetes (If yes, how are you treated?) Dietary treatment Tablet treatment Insulin treatment Lung diseaseAsthmaKOLCancer disease*YesNoa) What type of cancer do you have, or have had?*b) What year did you receive your cancer diagnosis?*c) If you have undergone an operation due to cancer, were on the body was it performed and when?*d) Is your health condition currently affected by your cancer?YesNoNeurological diseaseEpilepsyMultiple SclerosisParkinsonsBlood infection - HIV, Hepatitis B, Hepatitis C (If yes, which blood infection do you have or have had)? Hepatitis B Hepatitis C HIV Renal impairment (Kidney disease). If yes, please describe belowHepatic impairment (Liver disease). If yes, please describe belowDo you have any known bowel disease?*YesNoa) If yes, which?Have you recently had visible bleeding or mucus in your stool?*YesNoHave you recently suffered a weight loss that cannot be explained?*YesNoMandatory prostate questions for men:a) How often have you had the feeling that the bladder has not been completely emptied after urination?NeverHalf of the timeAlwaysb) How often have you had to urinate more often than every two hours?NeverHalf of the timeAlwaysc) How often have you had a disruption of the urine flow, ie the urine flow started, stopped and started again?NeverHalf of the timeAlwaysd) How often have you experienced that the urine beam was weak?NeverHalf of the timeAlwayse) How often do you usually have to go up to urinate from the time you go to sleep until you get up in the morning?Never1 time/night2 times/night5 times/nightf) Have you seen / had blood in the urine recently?YesNog) Have you had blood in the semen recently?YesNoh) If you recently have taken PSA-test, do you know if it was within normal range? (below 3.0 for men under the age of 70YesNoDon't knowIf yes, my PSA-level was (please enter the date you took the test)Do you have, or have had, any other medical condition that we have not asked about?*YesNoa) If yes, which?Have you undergone any major surgery (e.g. in bile, kidneys, uterus, ovaries, prostate)?*YesNoa) If yes, which?b) If yes, when? MedicationDo you use any medication at the moment?*NoYesWhich medication do you use? Hypersensitivity/AllergyAre you allergic to or experienced side effects from any medicines?*NoYesDon't knowDiscibe shortly what medicines are you allergic to: LifestyleDo your smoke?*NoUsed toYesa) Do you smoke or have smoked a packet of cigarettes a day for the last 10 years?NoYesb) Have you quit smoking less than 15 years ago?NoYesc) Did you smoke a package or more per day?NoYesHow much alcohol do you drink per week? (A standard glass corresponds to a glass of wine, 33cl beer, or 4cl spirits)*More than 10 standard glassesLess than 10 standard glassesI do not drink alcohol HeredityHas any of your (biological) parents, siblings or grandparents suffered from cancer?*NoYesDon't knowDo you know what type of cancer?Has any of your (biological) parents, siblings or grandparents suffered from cardiovascular disease?*NoYesDon't knowDo you know what type of cardiovascular disease?Does any of your (biological) parents or siblings have diabetes*NoYesDon't know Health Declaration prior to MRI examinationDo you have, or have had a pacemaker (cardiac stimulator)?*NoYesHave you undergone any surgery of your brain or heart?*NoYesDo you have a known liver or kidney disease?*NoYesDo you have, or have had, metal splits in your eyes or other body parts?*NoYesIf yes, please explain further:Do you have any implanted metals in your body, e.g. stag, shunt, pump, nerve stimulator, ear prosthesis? (Not valid for dental fillings, dental implants, prostheses, hip and knee prostheses, and screws in arms and legs.)*NoYesIf yes, please explain further:How tall are you (m)?*How much do you weigh (kg)?*Are you pregnant? (For female patient)YesNoAre you breastfeeding (For female patient)YesNoIs there anything else about your general health status that you think your doctor may need to know?Consent* I certify that the health information I provided in this health form is correct.*
