Testing of trombophilic mutations

Basic Informations

Name and surname: *

Health Insurance Company: *

Personal identification number (Birth number): * Enter the personal identification number with a slash.

Street: * Street including house number or orientation number.

Town: *

Postal Code (ZIP Code): *

Phone Number: * Enter in the format +420 ...

E-mail: *

Height: *

Weight: *

Medical Information

Are you currently using or planning to use hormonal contraception?: *

YES

Current illnesses (please list):

Are you currently taking any medications? (If yes, please list them.):

Past surgeries (please list):

Have you or anyone in your family had any cancer? (Please specify which family member, which organ, and at what age.):

Have you or anyone in your family had any of the following conditions? Please select one or more answers.:

infarctions

cerebrovascular accidents

blood clots

pulmonary embolism

none of the above

If you checked any of the listed conditions in your previous answer, please specify which family member it was and at what age.:

Have you had two or more spontaneous abortions?:

Have you experienced preeclampsia during your pregnancy, had a premature birth, placental infarctions, or fetal growth retardation?:

I agree with the processing of personal data.

Opište prosím kód z obrázku: