Chestionar Medical – Engleza

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  • Chestionar Medical – Engleza

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Chestionar Medical - Engleza
Category examined
Sex
Last inspection for transport safety:
You have been designated unfit for transport safety?
You have health problems (e.g. diabetes, hypertension, cancer, kidney disease, amputations, etc.)
Have you had any work-related health problems or accidents since your last examination?
Have you had any illnesses, accidents, injuries, poisonings requiring hospitalization or surgery in the last 5 years?
Have you ever been psychologically examined?
Are you currently taking any medication?
If Yes, please specify medications and dosage
Do you smoke?
Do you drink alcoholic beverages?
Do you use drugs or ethnobotanical substances?
Have you had or do you have any of the diseases below?
Please answer each question; if your answer is YES, please specify under comments.
Eye diseases/eye operations
Sleep apnea syndrome
Cardiac diseases
Diabetes
Dizziness, cases fainting, loss of con-sciousness
Mental problems
Diseases gastro- intestinal
Cancer
Insomnia
Detoxifications due to alcohol, medica-tion, drugs
Deafness
Diseases kidney
Epilepsy, paralysis
Asthma or of the lungs
Diseases of blood (e.g: anemia)
gravid Women Only: Are you pregnant?
Remarks: Being aware of the provisions of Article 326 of the Penal Code(Romanian ) on false statements, I declare on my own responsibility that the above data are true, complete and correct in every detail.
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