Medical questionnaire

    Personal data





    Sex * MaleFemale


    Please check the appropriate boxes

    Liver and pancreatic diseases

    Hepatitis

    Diabetes

    YesNo

    Cancer

    YesNo

    SurgeryRadiotherapyChemotherapy

    Thyroid disease ?

    Yes

    Cardiac disorders

    Heart attack

    StentChest anginaArterial hypertension

    Infections

    HIVTuberculosis

    Your habits

    Do you smoke ?

    YesNo

    Do you drink alcohol ?

    YesNo

    Allergies

    YesNo

    Articular rheumatism

    YesNo

    Respiratory disorders

    AsthmaEmphysema

    Have you already had a cell therapy ?

    YesNo


    Other illnesses

    Do you take medications ?

    YesNo

    Address


    Health Center Clinique Lémana
    Chemin de l’Hôtel Mirador 5
    CH – 1801 Le Mont-Pèlerin
    Switzerland

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    Contact


    Phone: +41 (0)21 961 38 12
    Fax: +41 (0)21 961 38 13
    admin @ lemana.com

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