Patient Questionnaire - Научно-исследовательский Институт Гипертермии

Questionnaire before conducting peak systemic hyperthermia

Full name Date of birth Nationality Аddress Telephone number Age Height Body mass Gender Profession Сommunication methods : Mobile communicationWhatsAppTelegramE-mail To prevent possible risks, please, answer the following questions in detail. If necessary, we will help You fill out the document. 1. Are you registered at the dispensary ? If so, which specialist? 2. There have been symptoms of the disease for the last four weeks (cold, fever, diarrhea)? If yes, please provide the exact information 3. Is there a history of any infectious diseases?(Hepatitis A,B, tuberculosis, syphilis, HIV/AIDS)? If yes, please provide the exact information and dates 4. What medications do you take regularly (drugs that prevent blood clotting (Мarcumar ,Aspirin®,Plavix ,Xarelto ,Pradaxa, Eliquis® ,lixiana, Heparinum ), If yes, please provide the exact information. Duration of administration and dosage 5. Do you have any allergic reactions?( allergic rhinitis or allergic asthma, / intolerance of substances (for medicines , to latex, MEANS OF DYSENFECTION, Anaesthetic, RADIOPAQUE SUBSTANCES, IODINE, medical tape, POLLEN ALLERGY)? If yes, please provide detailed information. The severity of the allergic reaction 6. Have you had any medical operations? When and what types of medical operations have you had 7. Do you have a tendency to bleed (AS WELL AS CLOSE RELATIVES), BLEEDING FROM THE NOSE OR GUMS, BRUISES ON THE SKIN? REPEATED BLEEDING AFTER SURGERY? ARE THERE ANY DISEASES ASSOCIATED WITH BLOOD CLOTTING? REPEATED BLEEDING AFTER SURGERY 8. Is there a history of vascular disease?( atherosclerosis, aneurysm, varicose veins? If yes, please provide the exact information) 9. Do you have cardiovascular diseases?( heart defect, heart valve defect, angina pectoris, myocardial infarction, apaplesia, cardiac arrhythmia, inflammation of the heart muscle, high blood pressure. If yes, please provide detailed information. 10. Is there a history of cardiovascular diseases?(heart defect, heart valve defect, angina pectoris, myocardial infarction, apoplexy, cardiac arrhythmias, inflammation of the heart muscle, high blood pressure, stroke) If yes, please provide detailed information. 11. Is there a history of lung and respiratory tract disease (bronchial asthma, chronic bronchitis, pneumonia, eczema of the lungs, respiratory failure, endobronchial formation. If yes, please provide the exact information 12. Is there a history of diseases of the digestive system (ESOPHAGEAL DISEASE, STOMACH DISEASE, PANCREATIC DISEASE, INTESTINAL DISEASE)? If yes, please provide the exact information 13. Is there a history of liver/gallbladder/biliary tract disease (INFLAMMATION OF INTERNAL ORGANS, LIVER STEATOSIS, cirrhosis of the liver,gallstone disease)? If yes, please provide the exact information 14. Do you have a history of kidney or urinary tract diseases?(renal failure, inflammation of kidneys, kidney stones, bladder infection)If yes, please provide the exact information 15. Is there a history of metabolic diseases?(diabetes mellitus,gout)If yes, please provide the exact information 16. Is there a history of the disease thyroid gland? (hyperactive thyroid, hypofunction thyroid, goitre) If yes, please provide the exact information 17. Is there a history of diseases of the musculoskeletal system ?(muscle weakness, joint disease, osteoporosis) If yes, please provide the exact information 18. If there is a history of diseases of the nervous system ?(paralysis ,convulsions ,epilepsy,сhronic pain) If yes, please provide the exact information 19. Is there a history of ophthalmic diseases ?(cataract of the eye, glaucoma)If yes, please provide the exact information 20. Аre there any other diseases?(spinal injuries, multiple sclerosis,restless leg syndrome, frequent headaches ,depression ,eye diseases, hearing impairment, mental illness, pustular skin diseases) If yes, please provide the exact information 21. Аre there implants in the body?( pacemaker, defibrillator, heart valve,cardiac stent) If yes, please provide the exact information 22. Have you already done the hyperthermia procedure? If yes, how many times 23. What complications were there after undergoing hyperthermia?If yes, please provide the exact information 24. How did you know about our Institute of hyperthermia in Novosibirsk? 25. Did you know that hyperthermia refers to research activities? 26. Are you ready to participate in the research program? 27. Do you need a transfer to the institute? Where to pick you up on an atomobile? 28. Do you need a hotel before the start of the study? 29. Do you need help finding a hotel and booking it? 30. Do you have a special diet?Do you have features that affect your accommodation? 31. Аdditional questions for women 1. Is there a chance of pregnancy? 2. Breastfeeding a baby? 3. Dates of a woman's menstruation