Registration form




RH0065-EE01CU

MEDICLUB REGISTRATION FORM

370000 Baku,  Azerbaijan  45 U. Hadjibekov St                                                                                                Please fill the form clear and use only words
   Tel 970-911/ -912/ -913      Fax 98-70-96

 

                  ____________________________________________      ______________________________   __________________________________

                                                          Surname                                                                   Other name                                                             

Date of birth

Sex

Pasport 
                                          

Citizenship

Blood group

Baku address and telephone

Job title

Company, company telephone №, company address

Height

Weight

Marital status
children (own)


Reason to release from
military service


Is there a family history of: heartdesease, high blood pressure, diabetes, cancer
Family history: relatives, children, brothers/sisters


Have you ever smoked?   YES/NO

Current week usage cigarettes        

Current week usage of alcohol?

Have you ever taken drugs, including drugs with doctors prescribtion?

 

TO THE NEXT QUESTIONS PLEASE MARK YES/NO IF YOU MARK «YES», PLEASE PUT NUMBER OF THIS QUESTION TO THE SECTION FOR ADDITIONAL ANSWERS.
IN THE SAME ROW PLEASE NOTE DATES, DISEASES, COMPLICATIONS, TREATMENT, DRUGS, PRESENT CONDITIONS.

                                                                                                                                                                                                                                                                                                     YES        NO


1. Have you been hospitalized any time? (details: hospital, department, what time)

 

 

 

 

2. Have you been  seen by doctor within last two years? (details: reason, result, treatment)

 

 

 

 

 

3. Have you ever had an operation or blood transfution (in details)?

 

 

 

 

 

4. Have you had ECG, X-ray (chest, digestion, kidneys, bones)? 
     Functional investigations, heart cateterisation, computer tomography, cat scan, blood and urine analysis, occult blood analysis (in details: reasons,
     dates, results).

 

 

 

 

 

5. Have you had investigations for cancer: radiation mamographie, CT scan, oncographie, biopsi, X-ray??



 

 

 

6. Have you had AIDS test?

 

 

 

 

 

7. Do you have any problem with health now?


 

 

 

8. Are you taking any prescribed drugs or medicines at present (in details)?

 

 

 

 

 

9. Do you have any allergy for medicines?

 

 

 

 

 

10. Do you have some troubles with health which not mentioned above?

 

 

 

 

 

DETAILS FOR POSITIVE ANSWERS

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I would like to have «MediClub» Company’s card (private or family)
I read the rules  . . . . . . . . . . . . . . . . . . . . . . . . . .  Signature
             . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Date      . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Expiry date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Surname

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Number of card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receiver’s signature, date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Card given by: date, signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cash or transfer  
payment order №  transfer date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
amount  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .