Albador AM Advanced Medicine – Medical Profile Questionnaire – ENG

Albador AM Advanced Medicine
Medical Profile Questionnaire – ENG

This form is used to create the diagnostic profile of patients who are interested in adjunctive therapy with AlbaDOR PB 9-5E2C®.

PERSONAL DATA MANAGEMENT STATEMENT
The data will be treated confidentially and used exclusively for creating the individual diagnostic profile and the initial assessment of treatment success.

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1/2. DATA OF THE MEDICAL INSTITUTION

Medical institution *

First

Middle

Last

Name of the doctor *

First

Middle

Last

Email address of the doctor *

2/2. DATA OF THE PATIENT

Name of the patient – Not requested – Only for the medical institution if needed

First

Middle

Last

Reference number of the patient

DATA = address

Gender *MaleFemaleOther

Year of birth *

Height / cm

Weight / kg

Current diagnosis *

List of medications *

Other information about the health condition or the current treatment *

Satisfaction rating of this questionnaire (0 = low, 10 = high)

Selected Value: 0

Consent to medical purposes *

• By submitting this Albador AM Advanced Medicine – Medical Profile Questionnaire – ENG, I agree to the use of my personal information for medical purposes.

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