Anmälan till Psoriasisskolan Skövde
Namn: ___________________________________ Personnummer:_____________________
Adress: _____________________________________________________________________
Postadress: _______________________________ Telefonnummer dagtid:________________
Mobil: ______________________________ E-postadress: ____________________________
Jag har psoriasis ( ) Sjukdomsdebut år: _____ Psoriasisartrit ( ) Sjukdomsdebut år: ______
PPP ( ) Sjukdomsdebut år: ___
Inflammatorisk tarmsjukdom ( ) Inflammatorisk ögonsjukdom ( ) Högt blodtryck ( )
Diabetes typ 2 ( ) Höga blodfetter ( )
Övriga riskfaktorer:
Övervikt ( )
Röker ( )
Snusar ( )
Min läkares namn och kontaktuppgifter (frivillig uppgift)
Namn: _____________________________________________________________________
Arbetsplats:__________________________________________________________________
Telefon: ____________________________________________________________________
E-postadress: ________________________________________________________________
Min sjukdom har för mig inneburit… (positivt och negativt):
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Blanketten fortsätter på sidan 2.
Jag vill gå Psoriasisskolan för att lära mig mer om..…
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För att öka min livskvalitet vill jag….…
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Livsstilsförändring jag funderar på att göra…
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Övrigt :
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Skicka anmälan till:
Anja Näslund
Psoriasisförbundet
Box 5173
121 18 Johanneshov
eller
[email protected]
