{"id":47,"date":"2022-04-27T11:55:09","date_gmt":"2022-04-27T04:55:09","guid":{"rendered":"http:\/\/vznsks.tmweb.ru\/?page_id=47"},"modified":"2025-04-11T12:50:54","modified_gmt":"2025-04-11T05:50:54","slug":"anketa-pacienta","status":"publish","type":"page","link":"https:\/\/sib-niig.com\/en\/pacientu\/anketa-pacienta\/","title":{"rendered":"Patient Questionnaire"},"content":{"rendered":"\n<div class=\"anketa\">\n<div class=\"page_title\">Questionnaire before conducting peak systemic hyperthermia<\/div>\n<div class=\"wp-block-contact-form-7-contact-form-selector flex-st\">\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f269-o1\" lang=\"ru-RU\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/47#wpcf7-f269-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"269\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.6.1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ru_RU\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f269-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<label> Full name\n    <span class=\"wpcf7-form-control-wrap your-fio\"><input type=\"text\" name=\"your-fio\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label> Date of birth\n    <span class=\"wpcf7-form-control-wrap your-birthday\"><input type=\"text\" name=\"your-birthday\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n<label> Nationality\n    <span class=\"wpcf7-form-control-wrap your-nationality\"><input type=\"text\" name=\"your-nationality\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label> \u0410ddress\n    <span class=\"wpcf7-form-control-wrap your-address\"><input type=\"text\" name=\"your-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label> Telephone number\n    <span class=\"wpcf7-form-control-wrap your-phone\"><input type=\"text\" name=\"your-phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label> Age\n    <span class=\"wpcf7-form-control-wrap your-age\"><input type=\"text\" name=\"your-age\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n<label> Height\n    <span class=\"wpcf7-form-control-wrap your-height\"><input type=\"text\" name=\"your-height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n<label> Body mass\n    <span class=\"wpcf7-form-control-wrap your-weight\"><input type=\"text\" name=\"your-weight\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label> Gender\n    <span class=\"wpcf7-form-control-wrap your-sex\"><input type=\"text\" name=\"your-sex\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n<label> Profession\n    <span class=\"wpcf7-form-control-wrap your-profession\"><input type=\"text\" name=\"your-profession\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<b>\u0421ommunication methods :<\/b>\n\n<span class=\"wpcf7-form-control-wrap your-communication\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"your-communication\" value=\"Mobile communication\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Mobile communication<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"your-communication\" value=\"WhatsApp\" \/><span class=\"wpcf7-list-item-label\">WhatsApp<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"your-communication\" value=\"Telegram\" \/><span class=\"wpcf7-list-item-label\">Telegram<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"your-communication\" value=\"E-mail\" \/><span class=\"wpcf7-list-item-label\">E-mail<\/span><\/label><\/span><\/span><\/span>\n\n<span class=\"wpcf7-form-control-wrap your-communication-detail\"><input type=\"text\" name=\"your-communication-detail\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n\n\n<span style=\"text-align:center; font-weight:bold\">To prevent possible risks, please, answer the following questions in detail. If necessary, we will help You fill out the document.\n<\/span>\n\n<label>1. Are you registered at the dispensary ?  If so, which specialist?\n    <span class=\"wpcf7-form-control-wrap question-1\"><input type=\"text\" name=\"question-1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>2. There have been symptoms of the disease for the last four weeks (cold, fever, diarrhea)? If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-2\"><input type=\"text\" name=\"question-2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-3\"><input type=\"text\" name=\"question-3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>4. What medications do you take regularly (drugs that prevent blood clotting (\u041carcumar ,Aspirin\u00ae,Plavix ,Xarelto ,Pradaxa, Eliquis\u00ae ,lixiana, Heparinum ),  If yes, please provide the exact information. Duration of administration and dosage\n    <span class=\"wpcf7-form-control-wrap question-4\"><input type=\"text\" name=\"question-4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-5\"><input type=\"text\" name=\"question-5\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>6. Have you had any medical operations? When and what types of medical operations have you had\n    <span class=\"wpcf7-form-control-wrap question-6\"><input type=\"text\" name=\"question-6\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-7\"><input type=\"text\" name=\"question-7\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>8. Is there a history of vascular disease?( atherosclerosis, aneurysm, varicose veins? If yes, please provide the exact information)\n    <span class=\"wpcf7-form-control-wrap question-8\"><input type=\"text\" name=\"question-8\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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. \n    <span class=\"wpcf7-form-control-wrap question-9\"><input type=\"text\" name=\"question-9\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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. \n    <span class=\"wpcf7-form-control-wrap question-10\"><input type=\"text\" name=\"question-10\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-11\"><input type=\"text\" name=\"question-11\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-12\"><input type=\"text\" name=\"question-12\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-13\"><input type=\"text\" name=\"question-13\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>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\n    <span class=\"wpcf7-form-control-wrap question-14\"><input type=\"text\" name=\"question-14\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>15. Is there a history of metabolic diseases?(diabetes mellitus,gout)If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-15\"><input type=\"text\" name=\"question-15\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>16. Is there a history of the disease  thyroid gland? (hyperactive thyroid, hypofunction thyroid, goitre) If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-16\"><input type=\"text\" name=\"question-16\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>17. Is there a history of diseases of the musculoskeletal system ?(muscle weakness, joint disease, osteoporosis) If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-17\"><input type=\"text\" name=\"question-17\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>18. If there is a history of diseases of the nervous system ?(paralysis ,convulsions ,epilepsy,\u0441hronic pain) If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-18\"><input type=\"text\" name=\"question-18\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>19. Is there a history of ophthalmic diseases ?(cataract of the eye, glaucoma)If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-19\"><input type=\"text\" name=\"question-19\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>20. \u0410re 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\n    <span class=\"wpcf7-form-control-wrap question-20\"><input type=\"text\" name=\"question-20\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>21. \u0410re there implants in the body?( pacemaker, defibrillator, heart valve,cardiac stent) If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-21\"><input type=\"text\" name=\"question-21\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>22. Have you already done the hyperthermia procedure? If yes, how many times\n    <span class=\"wpcf7-form-control-wrap question-22\"><input type=\"text\" name=\"question-22\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>23. What complications were there after undergoing hyperthermia?If yes, please provide the exact information\n    <span class=\"wpcf7-form-control-wrap question-23\"><input type=\"text\" name=\"question-23\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>24. How did you know about our Institute of hyperthermia in Novosibirsk?\n    <span class=\"wpcf7-form-control-wrap question-24\"><input type=\"text\" name=\"question-24\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>25. Did you know that hyperthermia refers to research activities?\n    <span class=\"wpcf7-form-control-wrap question-25\"><input type=\"text\" name=\"question-25\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>26. Are you ready to participate in the research program?\n    <span class=\"wpcf7-form-control-wrap question-26\"><input type=\"text\" name=\"question-26\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>27. Do you need a transfer to the institute? Where to pick you up on an atomobile?\n    <span class=\"wpcf7-form-control-wrap question-27\"><input type=\"text\" name=\"question-27\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>28. Do you need a hotel before the start of the study?\n    <span class=\"wpcf7-form-control-wrap question-28\"><input type=\"text\" name=\"question-28\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>29. Do you need help finding a hotel and booking it?\n    <span class=\"wpcf7-form-control-wrap question-29\"><input type=\"text\" name=\"question-29\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>30. Do you have a special diet?Do you have features that affect your accommodation?\n    <span class=\"wpcf7-form-control-wrap question-30\"><input type=\"text\" name=\"question-30\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<b>31. \u0410dditional questions for women <\/b>\n\n<label>1. Is there a chance of pregnancy?\n    <span class=\"wpcf7-form-control-wrap question-32-1\"><input type=\"text\" name=\"question-32-1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>2. Breastfeeding a baby?\n    <span class=\"wpcf7-form-control-wrap question-32-2\"><input type=\"text\" name=\"question-32-2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<label>3. Dates of a woman's menstruation\n    <span class=\"wpcf7-form-control-wrap question-32-3\"><input type=\"text\" name=\"question-32-3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label>\n\n<span class=\"wpcf7-form-control-wrap your-subject\"><input type=\"text\" name=\"your-subject\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"hidden-subj\" aria-invalid=\"false\" \/><\/span>\n\n<input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Questionnaire before conducting peak systemic hyperthermia<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":43,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"translation":{"provider":"WPGlobus","version":"2.8.11","language":"en","enabled_languages":["ru","en"],"languages":{"ru":{"title":true,"content":true,"excerpt":false},"en":{"title":true,"content":true,"excerpt":false}}},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v19.1 - 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