NorthernlightHospital

+47 77 66 48 50 | info@northernlighthospital.com

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It is crucial for your travel to us that you fill out this

Health declaration

To be sure of a safe and responsible treatment with Teres Medical Group, we ask you to answer following questions. Information will be kept as a part of your medical journal, it will be treated strictly confidential.
IT IS ALSO VERY IMPORTANT THAT YOU PROVIDE US WITH THE RESULT FROM A BACTERIAL SAMPLE TAKEN FROM YOUR NOSE (arrange this though your GP)

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Surname *
Forename *
Phone (home) *
Mobiltelephone *
E-mail *
Adress *
Height *
Weight *
Name and telephone number to next of kin *
Name and telephone number tothe person travelling with you *
Name and telephone number to your GP (General practitioner) *

Illnesses: Have you, or have you have had, any of the following illnesses:

Heartdisesase * Chest pain, myocardiual infarctions, arrythmias, abnormal breastless or hess when doing physical excersise No Yes
if yes, please specify
Hypertension * No Yes
Bleeding disorders * Trombosis, haemophilia, e.g No Yes
if yes, please specify
Neurological disorder * Stroke, brain hemorrage,epilepsy No Yes
if yes, please specify
Lung-airway disorder * Astma, COPD, snoring with breathing stop No yes
if yes, please specify
Diabets Mellitus * Diet-regulated, insulin injections, tablets No Yes
if yes, please specify
Kidney disorder * No Yes
if yes, please specify
Liver disorder * No Yes
if yes, please specify
Infection disorder * Hepatitis, HIV, tuberculoses, MRSA, NDM-1, or any other contagious illnesses No Yes
if yes, please specify
Psycological disorder * No Yes
Psychiatric disorder * No Yes
Allergies * NSAID, Penicillin, Latex, Acetylsalicylic acid or other allergies No Yes
if yes, please specify
Stomach problems or disorders * Gastric ulcer, heartburn, acid regurgitation, esaphageal regurgitation, No Yes
if yes, please specify
Rheumatic disorders * Reduced mobility or instability in the neck No Yes
if yes, please specify
General health information
Have you had any prevoius operation/anaestetisia * No Yes
if yes, please specify if you had any abnormal reaction with the anaesthesia or anaestetics
Have you been an in-patients in a hospital within the last six months? * No Yes
if yes, please specify why
Do you smoke * No Yes
if yes, please specify how many per day
Have you any problems to fully open your mouth? * No Yes
Do you breast feeding or are you pregnant? * No Yes
if yes, please specify
Do you use medications or any other drugs on a daily basis? * No Yes
if yes, please specify
Have you had any plastic surgery before? * No Yes
if yes, please specify
Any other health informations? If so, please specify *
Place and date *
Name of the person giving this information *

NorthernlightHospital

It is crucial for your travel to us that you fill out this

Health declaration

Travelinfo