Anamnesis form

Your health is very important to us. Therefore we would ask you in advance to fill out this questionaire completely. Based on the information you provide, we can get a first idea of your health condition and provide you a medical check up program tailored to your special needs. Of course, subject to your data with medical confidentiality and data protection.

Personal information
DOB*
Children
Diseases
Please indicate if you have had any of the following illnesses:
Do you have any allergies or intolerances?
Do you have any allergies or intolerances?
Diagnostik

Have you underdone surgery?

Medication

Do you regularly take medication (e.g. food supplements or vitamins)?

Do you take blood thinners?*
Nutritional profile
Do you eat regular?*
When do you have your main meal?*

Please note your nutrition during the day.

Stimulants
Do you suffer from food allergies or food intolerances?
Autonomic nervous system
Thirst*
Appetite*
Bowel movement*
Urinating*
Difficulty falling asleep*
Maintaining sleep*
Snoring*
Apnoe/respiratory failure:*
Night sweats*
Morning fatigue:*
Weight
For women
Regular cycle:
Birth control pills:
Menopause:
Are you pregnant?
Movement
Family history
Father
Mother
Mood/emotions
Mood / emotions
Pain history
Do you have often pain?*
How often do you have this pain currently?
Has the pain character changed?
Personal health goals

Do you have for you visit a specific request to us? Which examinations are particularly important to you? Which additional medical consultations are important to you?

How do you want to get your results?