New Admission, Anamnesis - Avismed - Ihr Hausarzt in Hanau

Neuaufnahme Anamnese

Updates

Basisinformationen
Datenschutz DSGVO
Beschwerden, Medikamente und Allergien
Vorerkrankungen & Operationen
Genussmittel
Regeluntersuchungen und Prävention

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 much
Your 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 name

Last name

Date of birth

Gender

Your home address

Street

House number

Postcode

City

Your 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 contacted

I would like to subscribe to the health information
We 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

How 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. 180

Your current body weight
in kg – please round to kg, e.g. 90

Blood pressure
If you know your last measured blood pressure, please enter it (e.g. 130/90)

Currently practiced activity / occupation

I 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

If 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 line

Emergency 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.

Yes

Please 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 card

According 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.

Why 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

Other

Reason for introduction Misc

What 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

Other

Complaints

How 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 months

Where do you have pain or complaints?

Do you regularly take medications?
If you are unsure, just skip this question.

Yes

Either 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.

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

What allergies / intolerances are you aware of?

Household products

House dust

Insect venom (bees, wasps)

Latex / rubber

Medications

Metals

Food

Plasters

Pollen

Animal hair

Other

Allergies

Which 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

Other

Allergies Other

Are you currently pregnant?

Yes

SSW

Are you currently breastfeeding?

Yes

Do 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)

Other

Diseases Other

What 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

Other

Heart disease Other

What 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

Other

Circulatory diseases Other

What lung disease do you have?

Asthma

COPD

Chronic bronchitis

Pulmonary fibrosis

Other

Lung diseases Other

What 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

Other

Cancers Other

What disease of the bones, muscles or connective tissue do you have or have you had?

Rheumatoid arthritis

Osteoporosis

Arthrosis

Increased bone fractures

Herniated disc

Other

Bone diseases Other

What mental or neurological disease do you have?

Dementia

Depression

Anxiety disorder

Parkinson’s disease

Multiple sclerosis

Migraine

Other

Psycho diseases Other

What metabolic disease do you have?

Diabetes Type I

Diabetes Type II

Hyperthyroidism (hyperthyroidism)

Hypothyroidism (hypothyroidism)

Lipid metabolism disorder (dyslipidemia)

Overweight

Other

Metabolic diseases Other

What 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

Other

Gastrointestinal diseases Other

What disease of the liver or bile ducts do you have?

Liver cirrhosis

Fatty liver

Hepatitis (inflammation of the liver)

Gallstones

Other

Liver bile diseases Other

What kidney/urinary tract disease do you have?

Kidney stones / bladder stones

Kidney inflammation

Chronic kidney insufficiency

Other

Kidney diseases Other

What eye disease do you have?

Cataracts (cataract)

Glaucoma (glaucoma)

Corneal disease

Disease of the retina (macular degeneration)

Other

Eye diseases Other

Have you ever had surgery?
This includes in particular major operations in adulthood. If unsure, skip the question.

Yes

Please list all major operations:
if possible with year

Do 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, but I would be interested in a consultation and creation

Do you smoke?

I am an ex-smoker

Yes, cigarettes

Yes, I smoke:

Smoking Other

How 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

How 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 week

Do you consume drugs (including cannabis, …)?

Yes

Which drugs do you take?

How often do you take these drugs?

Very rarely (less than 2x/year)

Occasionally (monthly)

Often (weekly)

Very often (daily)

When 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

Email for form submission

Signature (I hereby confirm my details)

Es ist ungewohnt mit der Maus zu unterschreiben. Keine Sorge – Ihre Unterschrift ist trotzdem genauso gültig wie auf Papier.