Questionnaire adults (male)
 
Dear Sirs,

to keep your time of waiting as short as possible, I would like to ask you kindly to answer the questions listed below. Your answers in the questionnaire give me a quick overview about your situation and I can focus on your interests and carry out administrative tasks after treatment.
Please fill in the questionnaire before your appointment and submit it by the button "submit data“ at the end of this questionnaire.
If you have pictures of imaging techniques (CT, MRI, X-ray, etc.), it would be helpful for the anamnesis to bring the last pictures to the appointment.

Surname
First Name
Street, Number
ZIP Code, Place (of residence)
Date of birth
Phone number/ mobile
E-Mail address
Health Insurance/ Supplementary Insurance
Occupation
Appointment

Reason of consultation:



Chronic diseases (Hypothyroiditis, cardiac arhythmias)



Accidents (even during childhood)



Medical Operations / Surgery: (i.e. artificial joints, gallstone removal)



Stool passage: hard/ pulpy/ liquid
regular (several times a day)/ irregular (only from time to time during a week)



Abdominal condition : flatulence/ bloating/ sensation of pressure or pain in umbilical area/ abdominal pain below your chest



Prostata



Urinary bladder: frequent urination (normal drinking)/ incontinence/ night dripping



Permanent medication: (i.e. hormones)



Sport activities



Dear Patient,
In case your appointment needs to be cancelled, please do it if only absolutely necessary and minimum 24 hours in advance.
Appointments which weren’t cancelled in time will be charged as a private bill according to the law § 615 BGB!

Reference to corresponding fees