Personal consultation of the specialist

Name:

Last Name:

E-Mail

(obligatory)

Age:

years old

Height:

Cm

inches

Weight:

Kg

Pounds

Civil  
Status:

 

single engaged common-law married
widowed separated or divorced

Children: no yes     how many?

Professional:

Smoker:

no

yes

for how long?     
how many cigarettes per day?

ex-smoker :

i have quit for   years

Physical  
Activity:

sedentary life   
lead a physically active life  
practise sports (specify):
      
      for hours per week

Medical History of Family Illness:

From your father, mother, brothers or sisters:

There are no particular diseases
Diabetes
Heart Disease
High arterial pressure (arteriosis)
High levels of cholesterol
Other (specify):

Personal Medical History:

In the past, I have never had a significant disease
I am affected by:
I have been in hospital from:      
I have had prolonged therapy with medication (specify):      
In the past, I have undergone an andrological cure (specify):      
I consider my present state of health to be good
I suffer from hypertension
I am affected by diabetes
I am affected by prostate pathology (specify):      
I am currently taking no drug
I am currently taking the following medicine (specify):
     
Other comments, remarks (specify):
     

 

Describe the disturbances for which you have sought consultation: :

(If necessary, insert the results of the examinations undertaken)

Protection of Privacy

In compiling this module and pressing the key "confirming the request", consensus is implied regarding the treatment of information in compliance with the decree Italian Law 675/96.

Information according to Article 10, 1 from Law 675/96 in the matter of "Protection of Personal Information".

The information requested from you will be used by Dr Paolo Michele Giorgi, in full respect of the Law No. 675 of 31.12.1996 in the matter of "Protection of Personal Information" for the full connection with the activity of the Agency (consultation, use, precise and statistical processing) through an internal database.
You have the right, under your own responsibility, to refrain from confiding this information, but must be advised that in this case, it may prejudice your relationship with your doctor. At whatever moment, provided for in Article 13 of Italian Law No. 675 of 31.12.1996, you may seek consultation, modify or cancel this information by writing to:
Dr Paolo Michele Giorgi, Via Puccetti 49, 55100 Lucca, Italy


Before Sending this Form, Please check it over for the precision of the Information given



Proceeding with the forwarding of this Module, I fully confirm the veracity of the inserted information.

I declare with full responsibility that the information given concerning the state of my health to be absolutely correct.

The patient may consider archiving this correspondence for possible, future consultations or clinical visits with us or with other specialists.


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