Data
Questions
years
cm.
kg
Times per day
Do you smoke?
Daily alcohol consumption?
Do you pratice any sport? If Yes, then state how often?
Does your job involve sitting? If yes, how much of your day do you spend sitting?
Have you had any congenital anomalies or malformations? If yes, what are they?
Do you have any acquired disabilities as a result of an accident? If yes, what are they?
Have you been assigned a % disability by TELC (NELC)? If yes, when, for what and how much %?
Do you have a diagnosed chronic illness? If yes, what?
Have you had or been recommended surgery? If yes, when? For what?
Have you been treated for more than 30 days in the last 2 years? If yes, for what diseases? Where was the treatment conducted?
Do you take any medicine? If Yes, then state the reason and what type of medication.
Do you have any allergies and/or autoimmune diseases? If yes, what are they?
Do you have or have you had orthopedic diseases (bone fractures, injuries to joints and ligaments of the articular apparatus, inserted osteosynthesis materials and implants, etc.)? If yes, what kind?
Do you have or have you had any diseases of the cardiovascular system (hypertension, angina pectoris, ischemia, heart attack, angina pectoris, etc.)? If yes, what exactly?
If you or your parents, grandparents, brothers, sisters or children suffer from or have any of the diseases listed below, please mark. If you mark the answer Yes that any of the listed relatives have been diagnosed with such diseases, please describe who it is.
Do you suffer or have you suffered from a respiratory disease (chronic bronchitis, emphysema, bronchial asthma, tuberculosis, occupational lung disease, etc.)? If Yes, what
Do you suffer from endocrine system diseases (diabetes mellitus, thyroid diseases, pituitary diseases, etc.)? If yes, what?
Do you have or have you had any diseases of the nervous system (discopathy, herniated disc, brain, head or spine injuries, strokes, paresis, epilepsy, radiculitis, polyneuropathies, etc.)? If yes, what?
Do you have or have you ever had any diseases of the urinary system (kidney stones, chronic renal failure, pyelonephritis, glomerulonephritis, etc.)? If yes, what?
For Women - Do you have or have you had any gynecological diseases (fibroids, heavy bleeding, cervical disease, ovarian cysts, ovarian dysfunction, breast diseases, etc.)? If yes, what?
For Men - Do you have or have you had any diseases of the reproductive system (prostatic hypertrophy, prostate cancer, testicular diseases, etc.)? If yes, what?
Do you have a relative who has been diagnosed with and suffered from cancer? If yes, who and what kind of cancer?
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