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Har!du!eller!har!du!tidigare!haft!ngon!av!fljande!sjukdomar/tillstnd?!

!!!!!!!!!!!!!!!JA!!!!NEJ,

1.,HjrtD,eller,krlsjukdomar,(infarkt,,blodpropp,,derfrkalkning,eller,derbrck)?,,,,!

2.,Har,du,haft,ngra,strre,kroppsskador,(t.ex.,benbrott,,ledskada,eller,strckning)?,,,!

!,

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,!

!,

4.,Har,du,stickningar,,domningar,,knselbortfall,eller,nedsatt,kraft,i,armar?, ,

,!

!,

5.,Har,du,stickningar,,domningar,,knselbortfall,eller,nedsatt,kraft,i,ben?,

,!

3.,Har,du,ngon,gng,vrdats,inneliggande,p,sjukhus?,, ,

JA!!!!NEJ!

!!!!!JA!!!NEJ

,,,,!

!,

21.,Har,du,bortfall,av,syn,eller,smak?,

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7.,Har,du,hgt,blodtryck?,, ,

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22.,Lider,du,av,illamende?,,,

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8.,Har,du,diabetes?,, ,

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9.,Har,du,eller,har,du,haft,cancer?,, ,,,,!

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23.,Har,du,en,pgende,infektion,,
,,,,,,,(t.ex.,frkylning)?,
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!,

24.,Har,du,problem,med,cirkulationen?,

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11.,Fr,du,kortisonbehandling?,,

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25.,Har,du,ngon,hormonsjukdom?,

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12.,Har,du,ngon,ledsjukdom?,,

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26.,Har,du,huvudvrk,eller,kkbesvr?,

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27.,Har,du,ngon,gng,varit,med,om,,
,,,,,,,en,olycka?,,,
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!,

28.,Har,du,ngra,andra,sjukdomar,,
,,,,,,,eller,besvr?,,
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30.,Har,du,lndryggsproblem?,

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31.,Har,du,knDproblem?,

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32.,a.,Intar,du,ngra,lkemedel,?,,, ,

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6.,Har,du,lgt,blodtryck?,,

10.,Lider,du,av,yrsel?,,

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13.,Har,du,ngon,reumatisk,sjukdom?!

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14.,Har,du,ngon,skelettsjukdom?, ,,,,!

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15.,Har,du,ngon,blodsjukdom?,

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16.,Har,du,epilepsi?, ,

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17.,Har,du,besvr,med,mage,,
,,,,,,,eller,tarm?,,
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18.,Har,du,andningssvrigheter,,
,,,,,,,eller,hosta?,
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19.,Har,du,astma,eller,allergi?,

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20.,Har,du,ngon,neurologisk,,
,,,,,,,sjukdom?,,,
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!,

, 29.,r,du,gravid?,

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,,,,,,,b.,Om,ja,,,vilka?___________________________________,
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