Patient’s name Sex M / F Date of Birth Phone : HomeWork
Address: region settlement(city/town/village/other) name district _street(lane)
house # block#_____ apt.#
Place of employment department
name and nature of manufacture
Occupation dependant
Dispensa-rization started
Reason
Dispensarization stopped
Reason
Date
New address
(new workplace)
Dispensarization Address and workplace change
FINAL(VERIFIED) DIAGNOSES LIST
Date (dd,
mm, yyyy)
of visit
Final (verified) diagnosis
First time diagnosis (mark with +)
Physician’s signature
(write surname readably)
PERIODIC EXAMINATIONS
QUESTIONNAIRE RESULTS
(underline the relevant)
1. Have you noticed any changes in the size and colour of moles and pigmented spots?
YES or NO?
2. Have you noticed any ulcerations, fissures, growths, lumps, exfoliations?
YES or NO?
3. Do you have difficulties swallowing?
YES or NO?
4. Do you notice general weakness, decrease of appetite, ongoing weight loss, constant vomiting, belching, nausea, sensation of abdominal heaviness, abdominal pain, constipation, diarrhoea?
YES or NO??
5. Have you noticed blood in your urine and/or feces, black "tarry" feces?
YES or NO?
6. Do you have cough, hemoptysis, chest pain, hoarse voice?
YES or NO?
7. Have you noticed hardenings, lumps of mammary (breast) glands, ulcers, fissures in the nipple area, nipple discharge?
YES or NO?
8. Have you noticed bloody vaginal discharge not related to menses?
name and nature of manufacture
Physician’s signature