Medical History Questionnaire

All information marked with * is required.

1 Patient Records*

2 Address*

3 Living conditions

Do you have a life partner?

yes no

Do you have children?

yes no

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?	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10

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?

yes no

Do you have trouble falling asleep or sleeping at night?

yes no

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

yes no

5.2 Digestion*

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

yes no

5.3 Pain*

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

yes no

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	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10
	1 2 3 4 5 6 7 8 9 10

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		1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10
	New Ch G	1 2 3 4 5 6 7 8 9 10

8 Examinations*

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

yes no

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)?

yes no

Have you had any endoscopies/colonoscopies?

yes no

10 Allergies*

Do you have any known allergies?

yes no

Allergen/trigger	Type, name, effects
Antibiotics (Name)	yes no
Aspirin	yes no
Flowers	yes no
Animal hair	yes no
House dust mites	yes no
Pollen	yes no
Insect venom	yes no
Fungal spores	yes no

11 Medication*

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

yes no

12 Surgeries*

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

yes no

13 Skin / Hair / Lymph Nodes*

Have you noticed any skin changes/itching?	yes no
Do you suffer from hair loss?	yes no
Do you have swollen lymph nodes?	yes no

If swollen lymph nodes, where?	lower jaw	neck	under the armpits
in the groin	in the back of the knee	other

14 Eating and drinking habits, food intake and stimulants, intolerances*

Do you have any food intolerances?

yes no

How much do you usually drink per day?
0.5 litres	1 litre	1.5 litres	2 litres	3 litres	5 litres

Do you smoke?

yes no

Do you drink alcohol?

yes no

15 For women

Do you still have your period?

yes no

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.

How did you hear about us?

Recommendation
Normamed
Doctor or patient portal on the Internet, Qype, arzttermine.de etc.
Printed information/flyer
Television programme
Internet search engine
Social Media

BioNTech Pfizer
Johnson & Johnson
Moderna
AstraZeneca
Novavax
Other

Breast cancer
Cervical cancer
Skin cancer
Bowel cancer

Colorectal cancer
Prostate cancer
Skin cancer
Abdominal aorta

Medical History Questionnaire

1 Patient Records*

2 Address*

3 Living conditions

4 Your current state of health*

Your current complaints*

5.1 Sleep*

5.2 Digestion*

5.3 Pain*

5.4 Other current complaints*

6 Your Current Diseases*

7 Specifics*

8 Examinations*

Examinations / imaging procedures / screening*

9 Vaccinations*

Which vaccinations?*

Which vaccine:

If there were side effects, what were they?

Other vaccinations?

10 Allergies*

Allergy triggers

11 Medication*

If yes, which medicines?

12 Surgeries*

13 Skin / Hair / Lymph Nodes*

14 Eating and drinking habits, food intake and stimulants, intolerances*

15 For women

16 Preventive care*

16.1 Woman

16.2 Man

17 Sport, holidays, leisure*

Privacy policy*

How did you hear about us?

Have you been to countries with special health risks in the last two years?	yes no
Have you ever had a tick bite?	yes no
Have you been treated with antibiotics?	yes no

Which endoscopies	Reason?	When?

	Morning	Noon	Evening

Surgery?	Reason?	When?