Medical History Form – International PatientsHome / Medical History Form – International Patients Medical History Form – International PatientsΔ Newsletter Medical History FormPlease complete this form before your treatment. The information helps us assess your medical history and plan your treatment as safely as possible.Personal and contact informationFirst name SurnameDate of birthday/month/yearNational ID number For patients without a Norwegian personal ID number, please enter date of birth.AddressPostal codeCityCountryPhone numberPlease include country code.EmailTreatment and measurementsWhich treatment are you being assessed for? Metabolic and bariatric surgery Lipedema treatment Cardiac ablation / electrophysiology OtherIf other, please specifyHeight (cm)Weight (kg)BMIMedical historyDo you currently have, or have you previously had, any of the following conditions or symptoms?Blood clots or bleeding tendency Yes NoDetailsIf yes, please provide details.Stroke or TIA (transient ischaemic attack / mini-stroke) Yes NoDetailsIf yes, please provide details.Heart disease / heart rhythm disorders Yes NoDetailsIf yes, please provide details.Heart attack / angina / PCI (percutaneous coronary intervention) Yes NoDetailsIf yes, please provide details.High blood pressure (hypertension) Yes NoDetailsIf yes, please provide details.Asthma / COPD / lung disease Yes NoDetailsIf yes, please provide details.Liver disease Yes NoDetailsIf yes, please provide details.Kidney disease Yes NoDetailsIf yes, please provide details.Stomach ulcer and/or acid reflux Yes NoDetailsIf yes, please provide details.Immunosuppression or immune deficiency Yes NoDetailsIf yes, please provide details.Diabetes Yes NoDetailsIf yes, please provide details.Mental health condition Yes NoDetailsIf yes, please provide details.Sleep apnoea Yes NoDetailsIf yes, please provide details. For sleep apnoea, please state whether you use CPAP.Neurological disease Yes NoDetailsIf yes, please provide details.Neck problems or previous neck injury Yes NoDetailsIf yes, please provide details.Dentures or loose teeth Yes NoDetailsIf yes, please provide details.Medication, allergies, nicotine, alcohol and infection riskCurrent medicationPlease list all regular medication, including dose if known.Blood-thinning medicationPlease list any anticoagulants or blood-thinning medication, including aspirin, warfarin, clopidogrel, Pradaxa, Xarelto, Eliquis, Fragmin/Klexane or similar.Weight-loss medicationPlease state whether you have used, or currently use, weight-loss medication.AllergiesPlease list any allergies, including medication, food, pollen, animals, latex or other relevant allergies.Do you smoke? Yes NoDo you use other nicotine products? Yes NoThis may include nicotine pouches/snuff, e-cigarettes, patches or similar.Alcohol use / recreational drugsIf you drink alcohol, please state the number of alcohol units per week. Please also mention any recreational drug use.Are you pregnant? Yes NoIf yes, please state how many weeks pregnant you areMRSA test status Negative PostiveDate of MRSA testDo you currently have an infection or contagious disease? Yes NoIf yes, please provide detailsPrevious surgery and local doctorPrevious operationsHave you previously had surgery? If yes, please state what type of surgery and when. Please also mention if you have ever felt unwell after anaesthesia.Previous illnesses / other relevant medical informationPlease include any other information you believe may be relevant for your assessment or treatment.Local doctor / GPPlease provide the name and clinic of your local doctor / GP.Local specialist / hospital contactIf you have a relevant local specialist, please provide name, clinic/hospital and contact details.Insurance, payment and medical tourismHow do you plan to pay for treatment? Self-pay Private health insurance Public reimbursement / prior authorisation OtherInsurance provider / recommended route Medical Shield (UK patients) AXA (EU/EEA patients) Other insurer No insurance / self-payUK patients are advised to check Medical Shield. EU/EEA patients are advised to check AXA or equivalent insurance.Insurance policy number / reference Insurance detailsPlease provide insurer name, policy/reference number and any relevant authorisation details.Insurance confirmation I confirm that I am responsible for checking that my insurance covers planned medical treatment abroad, complications, extended stay, travel changes and medical repatriation.Medical documentation confirmation I confirm that the information provided is complete and accurate to the best of my knowledge. I understand that I may be asked to provide medical records, test results or additional information before a final treatment decision is made. I have read the privacy notice and consent to IbsenSykehusene processing the information submitted in this medical history form for assessment, treatment planning and patient administration.Submit medical history form
