Questionnaire



If you have decided on the date of your arrival and booked a room, please fill out this form. It will help us to choose in advance the individual and most successful restorative program of your stay.
The information contained in the questionnaire is strictly confidential and will be used in preparation for your course of therapy exclusively by the doctors of the medical center.
Thank you for your efforts! The team of the resort complex "Rixos-Prykarpattya" wishes you a happy journey to us!
Fields with a star (*) are obligatory for filling.

   
Personal information
First name*
Last name*
Date of birth*
City
Country
E-mail*
Phone number*
Marital Status
Course
Starting Date of the Course*
Course Duration
How did you learn about us?
Your complaints
Other medical disorders and complaints
Any serious medical disorders or accidents have happened to you before?
Hospital stay. Have you ever been hospitalized? (year, the reason)
Has anyone in your family had following diseases? If yes, please, note.
High blood pressure
Heart attack
Stroke
Diabetes
Arterial lungs trombosis
Carcinology
Other
Current complaints
Pain
Do you often notice any kind of pain?
Since when do you notice it?
How often do you notice pain now?
Any changes in your health condition recently?
Any connection of your pain with the certain event or work?
Indicate the sensation of your pain level (1- very weak, 10- very strong)
Allergic deseases
Do you have any allergic reaction? If yes, to what?
What are the symthoms of allergic reaction?
Immune system
Іnfectious diseases (times per year)
With fever
Swollen lymph nodes
Diagnostics. Have you had recently the following examination?
X-ray. What areas?
Bloodtest, when?
Gynecological examination, when?
Ultrasound abdomen examination, when?
Other abdomen examination, when?
Intestine examination, when?
CT scan, MRI, when?
Nuclear medical diagnostics (scintigraphy), when?
What medication or supplements (nutrition supplements or vitamins) do you take?
Have you taken the following medication?
Meals nutrition characteristic
Do you have a regular breakfast?
Do you have a regular lunch?
What time do you have a lunch?
How long it takes you to eat?
Breakfast, min
Lunch, min
Dinner, min
Irregular nutrition
How often do you have a meal with friends (times in a week)?
What kind of food you can not deal with?
What kind of food intolerance do you have?
hat kind of food does your breakfast consist of?
Breakfast
Lunch
Dinner
Liquid
How many liters of liquid do you drink every day?
water
cups of tea
cups of coffee
liters of beer
milliliters of wine
milliliters of vodka
Nicotine. Specify the type and quantity per day (cigarette, cigar, pipe, hand-rolled cigarette).
Mobility
How do you estimate your mobility (body burden which is not knock the wind out of you. For instance, sharp walk, bicycling, climbing stairs etc)?
Distance you walk per day?
Do you go in for sports?
How often?
How long do you stay sit a day?
How long do you stay on open air?
Stress aspect
Your day working time, hours
Working time
How many short breaks (up to 10 min) do you have during the working-day?
For how long do you sleep per night?
How many days-off do you have during the week?
Your vacation duration per year?
When was your last vacation lasting more than a week?
How often do you visit the theatre, movie etc.?
How long do you usually stay with your family during the working-day?
How long do you communicate with nonprofessional contacts (minutes per day)?
Requirements to your activity?
Do you think about the work during your days-off or in the evening?
A question about the body type
Height, cm
Weight, kilo
Miscellanious
How do you treat yourself?
What is your hobby?
Doctor's advice
Need for additional consultations
I'd like to get a doctor's advice щт the following medical problems
Personal health-improving goals in Rixos Health Сenter
Medical alerts




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