QUESTIONS RELATED TO A MEDICAL CONDITION OF OUR CLIENT (FOR DOCTOR)

This is a standard list – please note that some of the points do not apply to certain medical cases

Patient’s name & surname:

Date of birth:

OUT-patient: Date of the visit(s):

IN-patient: Admission date: hour:

Estimate discharge date: hour:

DIAGNOSIS:

CIRCUMSTANCES: (important in case of traumas, accidents)

ALCOHOL / DRUGS INVOLVED: NO YES

PAST MEDICAL HISTORY: NO YES – please specify:

CURRENT TREATMENT:

FURTHER TREATMENT RECOMMENDATIONS: (if applicable)

IS SURGERY RECOMMENDED? NO Name and type of the surgery:

(if applicable)
YES – please specify How long can it be postponed from the date
of the accident: (days/hours)
EARLIEST TIME OF POSSIBLE REPATRIATION FOR FURTHER TREATMENT TO HOME COUNTRY (if applicable):

DATE/ TIME PERIOD: DESTINATION: HOME HOSPITAL

ADVICED FORM OF TRANSPORT BACK TO HOME COUNTRY (if applicable)

No special conditions Ground ambulance Regular flight Air ambulance

(Car/bus/train/airplane)
Sitting position
OTHER REMARKS (Oxygen etc):
Leg elevated / extra seat

Lying position / stretcher

Wheelchair needed

ESCORT REQUIRED: NO ESCORT CIVIL ESCORT NURSE DOCTOR

RECOMMENDED TRANSPORT TO AIRPORT: TAXI GROUND AMBULANCE

OTHER REMARKS:

Doctor’s signature and stamp

The above information is to be viewed by qualified doctors and is understood as strictly confidential.
Thank you for your help and co-operation. We kindly ask you to send the filled-in form to our fax or e-mail address.

Fax: 0040 21 2019040 E-mail: assistance@ro.april.com

If you have any questions, do not hesitate to call us, our Phone: 0040 21 2019030