Heilsufarsspurningar Medical Park sjúkrahúsanna vegna þyngdarlækkandi aðgerðar Please enable JavaScript in your browser to complete this form.Nafn / Name *FirstLastKyn / Sex *MaleFemaleOtherSími / Phone *Email *Kennitala / Date of birth *Hæð / Height:Núverandi þyngd / Current weight: *Mesta þyngd / Max weight in the past: *BMI - Reiknivél - https://mni.is/mni/calculations.aspx *Fyrirhuguð aðgerð / Planned treatment *Magaermi / Gastric SleeveHjáveita / Gstric BypassÖnnur / OtherEf önnur - Hver þá / If other - Witch?Ertu með sykursýki / - Do you have diabetes? *JáNeiErtu með langtíma sjúkdóm / Do you have any chronic disease? *JáNeiEf svo er lýsið / Please describeTekur þú lyf reglulega / Do you take any regular medications? *JáNeiEf svo er lýsið / Please describeHefur þú farið í ÞLA áður / Have you had a weight loss surgery before? *JáNeiEf svo, hvenær (dagsetning), hver er heildar þyngdarlækkun og ertu enn að léttast? / If yes, when (date), what is the total weight loss and say if you are still losing weight.Hefur þú farið í stóra skurðaðgerð áður / Did you have any major surgery before? *JáNeiEf svo, vinsamlegast hvernig og hvenær / If so, please describe witch and the dateEitthvað sem þú vilt taka fram að lokum / Something you like to add?Heimilisfang / Address *Address Line 1CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountrySamþykkir sjúklingurinn meðhöndlun og varðveislu persónulegra upplýsinga / Has the patient agreed to the processing and collection of personal data ? *JáNeiLEYFI TIL MEÐHÖNDLUNAR PERSÓNULEGRA UPPLÝSINGA / CONSENT TO PROCESSING OFF PERSONAL DATA Ég veiti hér HEI Medical travel samþykki mitt fyrir meðhöndlun persónuupplýsinga um mig og til að deila þeim með viðkomandi samstarfsaðilum svo sem Medical Park sjúkrahúsunum og til að eyða þeim þegar þeirra gerist ekki lengur þörf, samanber lög nr. 90/2018 um persónuvernd og vinnslu persónuupplýsinga og reglugerð Evrópuþingsins og ráðsins (ESB) 2016/679. I hereby give HEI Medical travel specific, unambiguous consent to process my personal data and to share it with relevant co-operators as suppliers of healthcare service such as the Medical Park hospitals and to delete it when it is not needed any more at HEI, as defined in Icelandic laws no. 90/2018 on personal protection and processing of personal data and Regulation (EU) 2016/679 of the European Parliament and Council.Senda / Submit
