Annabelle Vogel & Kollegen

Ihr Partner in Hanau

für Gesundheit & Prävention

German

Reason for Visit

Besuchsgrund

Newsletter

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

Email

In order for us to know your reason for visiting for the upcoming appointment and to prepare the appointment optimally, please fill out this short questionnaire.

Reason for visit

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)

Blood collection

Other

Reason for visit Other

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 complaints/allergic reaction

Skin problems

Dizziness, fainting

Problems with urination

Problems with bowel movements

Stress, psychological problems

Other

Complaints Other

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?

For which disease(s) do you need the appointment?

Cardiovascular disease (e.g. heart failure, high blood pressure)

Lung disease (e.g. COPD, asthma)

Gastrointestinal disease

Mental illness

Metabolic disease (diabetes, thyroid disease)

Diseases of the liver or kidneys

Other

Diseases Misc

I would like to receive a copy of this form (and, if applicable, the information on data protection) as a PDF to the following email (the PDF is in german, even though this questionnaire is in english for your convenience).

Yes

No

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.

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Gesundheits-Infos

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aktuellen Gesundheitsthemen
Impfungen, Vorsorgeuntersuchungen
Änderungen in der Praxis (Urlaub, Öffnungszeiten, neue Mitarbeiter, …)
…

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