Questionnaire adults (male)
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
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.
ZIP Code, Place
Date of birth
Phone number/ mobile
Health Insurance/ Supplementary Insurance
Reason of consultation:
Chronic diseases (Hypothyroiditis, cardiac arhythmias)
(even during childhood)
Medical Operations / Surgery:
(i.e. artificial joints, gallstone removal)
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
frequent urination (normal drinking)/ incontinence/ night dripping
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