Hälsoformulär – MR Helkropp + Hjärtundersökning - EN

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?*
- Employee
- Business Owner
- Pensioner
- On sick leave
Describe 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*
- Yes
- No
Cardiovascular 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 disease
- Asthma
- KOL
Cancer disease*
- Yes
- No
a) 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?
- Yes
- No
Neurological disease
- Epilepsy
- Multiple Sclerosis
- Parkinsons
Blood 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 below
Hepatic impairment (Liver disease). If yes, please describe below
Do you have any known bowel disease?*
- Yes
- No
a) If yes, which?
Have you recently had visible bleeding or mucus in your stool?*
- Yes
- No
Have you recently suffered a weight loss that cannot be explained?*
- Yes
- No
Mandatory prostate questions for men:
a) How often have you had the feeling that the bladder has not been completely emptied after urination?
- Never
- Half of the time
- Always
b) How often have you had to urinate more often than every two hours?
- Never
- Half of the time
- Always
c) How often have you had a disruption of the urine flow, ie the urine flow started, stopped and started again?
- Never
- Half of the time
- Always
d) How often have you experienced that the urine beam was weak?
- Never
- Half of the time
- Always
e) 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?
- Never
- 1 time/night
- 2 times/night
- 5 times/night
f) Have you seen / had blood in the urine recently?
- Yes
- No
g) Have you had blood in the semen recently?
- Yes
- No
h) 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 70
- Yes
- No
- Don't know
If 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?*
- Yes
- No
a) If yes, which?
Have you undergone any major surgery (e.g. in bile, kidneys, uterus, ovaries, prostate)?*
- Yes
- No
a) If yes, which?
b) If yes, when?

Medication
Do you use any medication at the moment?*
- No
- Yes
Which medication do you use?

Hypersensitivity/Allergy
Are you allergic to or experienced side effects from any medicines?*
- No
- Yes
- Don't know
Discibe shortly what medicines are you allergic to:

Heredity
Has any of your (biological) parents, siblings or grandparents suffered from cancer?*
- No
- Yes
- Don't know
Do you know what type of cancer?
Has any of your (biological) parents, siblings or grandparents suffered from cardiovascular disease?*
- No
- Yes
- Don't know
Do you know what type of cardiovascular disease?
Does any of your (biological) parents or siblings have diabetes*
- No
- Yes
- Don't know

MR-Helkropp + Hjärtundersökning - EN

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Health Form

Diseases

Mandatory prostate questions for men:

Medication

Hypersensitivity/Allergy

Lifestyle

Heredity

Health Declaration prior to MRI examination