Medical History Questionnaire

All information marked with * is required.

1 Patient Records*
2 Address*
3 Living conditions

Do you have a life partner?

Do you have children?

4 Your current state of health*

Please give us an impression of your current state of health by marking the points, from rather good (green=1) to rather bad (red=10).

How would you rate your general health condition?
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Your current complaints*

Please give us an impression of how you rate your current complaints by marking the points, from rather good (green=1) to rather bad (red=10).

5.1 Sleep*

Do you suffer from chronic fatigue?

Do you have trouble falling asleep or sleeping at night?

Have you used medication to fall asleep or sleep through the night in the last 12 months?

5.2 Digestion*

Do you currently suffer from digestive problems (e.g. heartburn, cramps, flatulence, diarrhoea, soft stools, constipation) ?

5.3 Pain*

Do you currently have pain (e.g. headache, sore throat, chest pain, abdominal pain, etc.) ?

5.4 Other current complaints*

Please enter other current complaints here (e.g. shivering, sweating, itching, morning stiffness, trembling, tongue coating) and give us an impression of how you rate them by marking the points, from rather hardly, little, slightly, rarely (green=1) to rather very, strongly, much, frequently (red=10).

Please indicate only complaints here. Please provide information on recognised diseases (such as arthrosis, diabetes, blood coagulation disorders, bladder infections, etc.) separately in section 6!

Your current complaints
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6 Your Current Diseases*

Please give us an impression of how you rate your current diseases by marking the points, from rather mild, slight, little (green=1) to rather bad, strong (red=10). Please tick in each case whether it is a rather new disease, a chronic disease (Ch, e.g. arthritis, rheumatism) or an underlying disease (G, e.g. diabetes, blood clotting disorder).

Your current diseases
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7 Specifics*

Do you suffer from high blood pressure?

Do you suffer from low blood pressure?

Do you have cardiovascular problems?

Are you a dialysis patient?

Do you have occasional stabbing pains or feelings of pressure under the right costal arch?

Do you occasionally have stabbing pains under the left costal arch?

Do you occasionally have swollen legs?

Do you have or have you had varicose veins on your legs?

Have you ever had angina pectoris/heart attack?

Have you ever had a thrombosis?

Do you suffer from infections?

8 Examinations*

Have you seen a doctor(s) in the last 12 months and have laboratory tests been done and/or diagnoses made?

Examinations / imaging procedures / screening*

Have you already had a diagnostic examination with one or more of the following devices/procedures: Ultrasound examination or sonography (e.g. abdomen, kidneys), MET (magnetic field resonance tomography or also magnetic resonance imaging), Radiography/X-Rays (general), CT (computer tomography), PET-CT (positron emission tomography), teeth (all imaging procedures around the teeth)?

Have you had any endoscopies/colonoscopies?

9 Vaccinations*

Have you been vaccinated?

10 Allergies*

Do you have any known allergies?

11 Medication*

Do you take medication permanently or at intervals? (also infusions, TCM medicines, homeopathic remedies and others)

12 Surgeries*

Have you had any surgery or are you currently planning any? Have you had any surgery or are you currently planning any?

13 Skin / Hair / Lymph Nodes*
Have you noticed any skin changes/itching?
Do you suffer from hair loss?
Do you have swollen lymph nodes?
14 Eating and drinking habits, food intake and stimulants, intolerances*

Do you have any food intolerances?

How much do you usually drink per day?
Do you smoke?

Do you drink alcohol?

15 For women

Do you still have your period?

16 Preventive care*

Do you have preventive examinations (check-ups, prevention programmes, etc.)?

17 Sport, holidays, leisure*
Do you do sport regularly?
Do you go for a walk?
Have you been to countries with special health risks in the last two years?
Have you ever had a tick bite?
Place and date*
Privacy policy*

Regarding the transmission of my personal data and medical history answers, I have read the written information on the transmission of my personal data (download info sheet, as of 20.01.2022). I have also taken note of the data protection declaration.

I am aware that this data is personal health data requiring special protection within the meaning of Art. 9 DSGVO. By clicking on the button "Send medical history", I expressly agree to the digital transmission of my data to the MVZ Ärztehaus Mitte.

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