Skip to content
No results
Treatments
Arm
Revision of Elbow Joint Endoprosthesis Surgery
Comprehensive Tennis Elbow Treatment
Comprehensive Carpal Tunnel Syndrome Treatment
Treatment for Dupuytren’s Contracture
Elbow Endoprosthesis Surgery
Foot
Ankle Ligament Reconstruction
Torn Achilles Tendon Treatment
Hallux Treatment
Shoulder
Revision of shoulder joint endoprosthesis Surgery
Shoulder Endoprosthesis Surgery
Shoulder arthroscopy Surgery
Hip
Femoral Osteotomy Surgery
Hip arthroscopy Surgery
Surgical treatment of femoral fractures
Revision of Hip Joint Endoprosthesis Surgery
Total Hip Replacement (Direct Anterior Approach) Surgery
Hip replacement Surgery
Knee
Knee arthroscopy Surgery
Revision Knee Replacement Surgery
Knee Replacement Surgery
Andrzej Suwara
Cosmetic Treatments
Margareta Budner
Face Plastic Surgery
Nose correction
Face Lifting
Ear Correction
Surgery for Crooked Nasal Septum
Eyelid Surgery
Body Plastic Surgery
Arm Lift
Liposuction
Abdominoplasty
Breast Plastic Treatments
Gynecomastia surgery
Breast reduction
Breast Enlargement
About us
Contact
More
Opinions
Concierge Services
Blog
Treatments
Arm
Comprehensive Tennis Elbow Treatment
Revision of Elbow Joint Endoprosthesis Surgery
Comprehensive Carpal Tunnel Syndrome Treatment
Treatment for Dupuytren’s Contracture
Elbow Endoprosthesis Surgery
Foot
Hallux Treatment
Torn Achilles Tendon Treatment
Ankle Ligament Reconstruction
Shoulder
Revision of shoulder joint endoprosthesis Surgery
Shoulder Endoprosthesis Surgery
Shoulder arthroscopy Surgery
Knee
Knee arthroscopy Surgery
Revision Knee Replacement Surgery
Knee Replacement Surgery
Hip
Surgical treatment of femoral fractures
Hip arthroscopy Surgery
Femoral Osteotomy Surgery
Total Hip Replacement (Direct Anterior Approach) Surgery
Revision of Hip Joint Endoprosthesis Surgery
Hip replacement Surgery
Andrzej Suwara
Cosmetic Treatments
Dr. Margareta Budner
Body Plastic Surgery
Abdominoplasty
Liposuction
Arm Lift
Face Plastic Surgery
Nose correction
Face Lifting
Ear Correction
Surgery for Crooked Nasal Septum
Eyelid Surgery
Breast Plastic Treatments
Breast Enlargement
Breast reduction
Gynecomastia surgery
About us
Contact
More
Concierge Services
Opinions
Blog
REQUEST APPOITMENT
Search
Menu
Blank Form (#4)
First Name
Last Name
ID Card
Country of origin
Date of birth
Email
Gender
Male
Female
Height
Weight
Telephone number
Cranial injury
Yes
No
Cranial injury
Faintness
Yes
No
Faintness
Epilepsy
Yes
No
Epilepsy
Diseases of the nervous system
Yes
No
Diseases of the nervous system
Mental health problems
Yes
No
Mental health problems
Diabetes
Yes
No
Diabetes
Ear diseases
Yes
No
Ear diseases
Eye diseases
Yes
No
Eye diseases
Cardiovascular, hematologic or circulatory disease
Yes
No
Cardiovascular, hematologic or circulatory disease
Respiratory diseases
Yes
No
Respiratory diseases
Musculoskeletal system diseases
Yes
No
Musculoskeletal system diseases
Allergies
Yes
No
Allergies
Other health problems
Yes
No
Other health problems
Smoking
Yes
No
Smoking
Subjective health assessment
Pick one of the options
Good
Rather good
Rather weak
Very weak
Other
Other health assessment
Can you easily climb the stairs to the second floor or run to the bus?
Yes
No
Can you easily climb the stairs to the second floor or run to the bus?
Have you ever had surgery?
Yes
No
Have you ever had surgery?
Were there any complications connected to the surgery or anesthesia?
Yes
No
Were there any complications connected to the surgery or anesthesia?
Are you under care of any specialist clinic?
Yes
No
Are you under care of any specialist clinic?
Were you vaccinated against hepatitis? (type B jaundice)
Yes
No
Do you take any medications?
Yes
No
Do you take any medications?
Have you ever stayed in a hospital?
Yes
No
Have you ever stayed in a hospital?
Have you ever been pregnant?
Yes
No
Do you take any hormonal medications?
Yes
No
Do you take any hormonal medications?
Date of last menstrual period
Date of last visit to the gynecologist
Please describe your problem
For how long have you had this problem
What are the symptoms?
What kind of pain you feel?
Have you been diagnosed by a doctor? If so – what was the diagnosis and what kind of treatment your doctor proposed?
Submit Form