New Admission, Anamnesis Neuaufnahme Anamnese Newsletter Basic informationData protection GDPRConditions, medications and allergiesPre-existing conditions & surgeriesCigarettes, alcohol, ...Routine check-ups and prevention Welcome to your Practice Avismed! For an individual consultation and treatment, we ask you to provide some information about yourself and your medical history. Answering these questions is voluntary. Please also take note of the mandatory data protection information and the notification options. You can change your details or revoke declarations at any time (just speak to us).Thank you very muchYour Avismed team Please ensure that your details match the information on your health insurance card (so that we can correctly identify you). Questions marked with “*” are mandatory.First nameLast nameDate of birthGenderSelectFemaleMaleDiverseNo answerEmailYour home addressStreetHouse numberPostcodeCityYour primary phone number (mobile or landline)In order to be able to pass on messages such as lab results, appointment changes, ... to you quickly, we would like to contact you by phone or email depending on the urgency. Yes, I agree I do not want to be contactedI would like to subscribe to the health informationWe send out health tips with current information (e.g. vaccinations, ...) or innovations in the practice by email at irregular intervals (maximum 1x/month). You can unsubscribe at any time. You will receive an email with a confirmation link to click to complete the registration. Yes NoHow did you find us? Change of family doctor's practice Personal initiative Other (e.g. referral from a doctor)Who was your previous family doctor?Your current height in cm, e.g. 180Your current weight in kg - please round to kg, e.g. 90Blood pressure If you know your last measured blood pressure, please enter it (e.g. 130/90)Currently practiced activity / occupationI agree that we (the Avismed family practice) request treatment data and findings from me from other specialists and transmit them to other specialists?We would like to ask you to request current documents from your current family doctor yourself and bring them with you (experience has shown that we rarely receive a timely response to family doctor inquiries). We would then be happy to add the documents to your patient file. Yes NoIf you would like to name people (e.g. spouse, children, ...) to whom information about your treatment may be released, please enter their name, date of birth and contact details: Please enter one contact per lineEmergency data on health insurance card In an emergency, your health insurance card is read in the hospital. Medically relevant emergency information can be stored on the health insurance card. An emergency contact can also be saved. We can write this information on your health insurance card. Only possible if you have emergency-relevant diagnoses, such as allergies with allergic shock or taking blood thinners. No YesPlease enter the emergency contact (if it is the same person as above, simply enter “see above”) Please let the reception know when you read the card that you need to save emergency data on the health insurance cardPreviousNextAccording to the EU General Data Protection Regulation (GDPR), we are obliged to inform you about the purpose for which our practice collects, stores or forwards data. You can also find out what rights you have with regard to the protection of your data. Please read the information on data processing in accordance with GDPR. With your consent at the end of the form, we will send you the information on data processing by email.PreviousNextWhy are you coming to us? Reason for introduction Complaints (e.g. pain, cough, dizziness, rash, etc.) Prescription Sick leave certificate Preventive care/health check-up/check-up Vaccination/vaccination advice General discussion/consultation Specific illness (e.g. heart, lung, gastrointestinal) Routine examination Aftercare OtherReason for introduction MiscWhat complaints do you have? Pain Cold symptoms (runny nose, nasal congestion, hoarseness, sore throat...) Muscular complaints (swelling, redness, injury...) Joint problems Heart problems, blood pressure problems Respiratory problems (cough, asthma, COPD...) Gastrointestinal complaints (nausea, vomiting, heartburn, diarrhea...) Allergy symptoms / Allergic reaction Skin problems Dizziness, fainting Problems with urination Problems with bowel movements Stress, psychological problems OtherComplaintsHow long have you had complaints? For less than 24 hours For more than 1 day to 1 week For more than 1 week to 3 weeks For 1 to 3 months For more than 3 monthsWhere do you have pain or complaints?Do you regularly take medications? If you are unsure, just skip this question. Yes NoEither photograph medication plan If you have a medication plan in paper form, you can take a photo of your medication plan and upload it. Please make sure that the entire barcode is visible. Note: Click on 'Select or take an image', then select 'Camera' and click on the shutter button below or on the 'Select or take picture or type in medications Please list the medications you take regularly per line and, if known, the dosage and administration schedule. Don't forget natural remedies and vitamins!Are you aware of any allergies or intolerances? e.g. medications, food, animal hair If you are unsure, just skip this question. Yes NoWhat allergies / intolerances are you aware of? Household products House dust Insect venom (bees, wasps) Latex / rubber Medications Metals Food Plasters Pollen Animal hair OtherAllergiesWhich of the following allergic reactions have you ever experienced? I have never had an allergic reaction. Runny nose Watery eyes, itchy eyes Cough Skin rashes Itching Digestive problems Swelling of the face or tongue Shortness of breath Allergic shock OtherAllergies OtherAre you currently pregnant? No YesSSWAre you currently breastfeeding? No YesPreviousNextDo you suffer from any of the following diseases? Heart diseases (e.g. heart attack, angina pectoris, heart defect, myocarditis, cardiac arrhythmia) Circulatory / vascular diseases (e.g. stroke, circulatory disorders, high or low blood pressure, varicose veins, thrombosis, embolism) Lung diseases (e.g. COPD, asthma) Blood diseases or increased bleeding tendency (tendency to bruising or nosebleeds or bleeding gums, bleeding after injury or surgery) Cancers Diseases of the bones, muscles or connective tissue (e.g. rheumatism, arthrosis, osteoporosis) Mental, neurological diseases (e.g. dementia, depression, multiple sclerosis) Metabolic diseases (e.g. diabetes, thyroid over/underfunction) Stomach / intestinal diseases (e.g. heartburn/acid regurgitation, stomach ulcer, chronic intestinal diseases) Diseases of the liver or bile ducts (e.g. liver cirrhosis, fatty liver, hepatitis, gallstones) Kidney / urinary tract diseases (e.g. kidney inflammation, kidney/bladder stones) Eye diseases (e.g. cataracts, glaucoma, keratitis, macular degeneration) OtherDiseases OtherWhat heart disease(s) do you have or have you had? Heart attack Heart failure (cardiac weakness) Atrial fibrillation Cardiac arrhythmias (except atrial fibrillation) Heart defect OtherHeart disease OtherWhat circulatory/vascular diseases do you have? Stroke CHD (coronary heart disease) High blood pressure Too low blood pressure PAD (peripheral arterial occlusive disease; “intermittent claudication”) Varicose veins / Chronic venous insufficiency Leg vein thrombosis OtherCirculatory diseases OtherWhat lung disease do you have? Asthma COPD Chronic bronchitis Pulmonary fibrosis OtherLung diseases OtherWhat cancer do you have or have you had? Pancreatic cancer Breast cancer Colon cancer Cervical cancer Skin cancer Liver cancer Leukemia (blood cancer) Lung cancer Stomach cancer Prostate cancer OtherCancers OtherWhat disease of the bones, muscles or connective tissue do you have or have you had? Rheumatoid arthritis Osteoporosis Arthrosis Increased bone fractures Herniated disc OtherBone diseases OtherWhat mental or neurological disease do you have? Dementia Depression Anxiety disorder Parkinson's disease Multiple sclerosis Migraine OtherPsycho diseases OtherWhat metabolic disease do you have? Diabetes Type I Diabetes Type II Hyperthyroidism (hyperthyroidism) Hypothyroidism (hypothyroidism) Lipid metabolism disorder (dyslipidemia) Overweight OtherMetabolic diseases OtherWhat stomach/intestinal disease do you have? Gastritis (inflammation of the gastric mucosa) Stomach ulcer Chronic inflammatory bowel disease (Crohn's disease / Ulcerative colitis) Reflux disease OtherGastrointestinal diseases OtherWhat disease of the liver or bile ducts do you have? Liver cirrhosis Fatty liver Hepatitis (inflammation of the liver) Gallstones OtherLiver bile diseases OtherWhat kidney/urinary tract disease do you have? Kidney stones / bladder stones Kidney inflammation Chronic kidney insufficiency OtherKidney diseases OtherWhat eye disease do you have? Cataracts (cataract) Glaucoma (glaucoma) Corneal disease Disease of the retina (macular degeneration) OtherEye diseases OtherHave you ever had surgery? This includes in particular major operations in adulthood. If unsure, skip the question. Yes NoPlease list all major operations: if possible with yearDo you have a living will? With a living will, you determine whether you want medical interventions (e.g. resuscitation, ...) in certain situations (in which you can no longer decide for yourself). Yes No No, but I would be interested in a consultation and creationPreviousNextDo you smoke? I am an ex-smoker No Yes, cigarettes Yes, I smoke:Smoking OtherHow many cigarettes do you smoke approximately per day?For ex-smokers, how many cigarettes did you smoke approximately per day?How many years have you been smoke-free?Do you drink alcohol? Yes NoHow often do you drink alcohol? At most 1 time per month 2 to 4 times per month 2 to 3 times per week At least 4 times per weekDo you consume drugs (including cannabis, ...)? Yes NoWhich drugs do you take?How often do you take these drugs? Very rarely (less than 2x/year) Occasionally (monthly) Often (weekly) Very often (daily)PreviousNextWhen was the last time you had a skin cancer screening? The statutory health insurance pays for a skin cancer screening (skin cancer prevention) every 2 years for patients over 35 years. Please indicate the year and, if applicable, the treating doctor. Skip the question if you are unsure.We also offer skin cancer screening with video documentation (if interested, see: avismed.de/hautkrebsvorsorge-mit-videodokumentation). When was the last time you had a health check-up? The statutory health insurance pays for a health check-up every 3 years for patients over 35 years. Please indicate the year and, if applicable, the treating doctor. Skip the question if you are unsure.I would like a copy of this form (and the information on data protection) sent to the following email (the PDF is in german, even though this questionnaire is in english for your convenience): Yes NoEmail for form submissionSignature (I hereby confirm my details) Es ist ungewohnt mit der Maus zu unterschreiben. Keine Sorge - Ihre Unterschrift ist trotzdem genauso gültig wie auf Papier. Back Submit
