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SILOCARE

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Medical form

Please fill in the form below to better understand your medical condition. This information is important for your treatment and your health

First Name

E-mail address

Family name

Date of birth

Do you have health problems? if so, which ones?

Heart and vessels

Liver

Stomach bowel

Diabetes / Diabetes

Lungs

Kidneys

Thyroid

Epilepsy

Blood / clotting

Inflammation

Autism

Psychic

Allergies (latex, Penicillin, anesthetic, drugs ...)

Infectious disease (HIV, Hepatitis ...)

Others