Forms health

Height

Weight

Are there or have there been diseases, complaints or dysfunctions in the last 10 years?

1)... of the heart, circulatory system, vessels (e.g., pain in the cardiac region, heart attack, heart failure, dysrhythmia, physician-determined high blood pressure, stroke, vascular changes, circulatory disorders, thrombosis)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

2)... the lungs, bronchi, trachea, nose (e.g., inflammation, asthma, chronic bronchitis, sleep apnea)

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

3)... the esophagus, stomach, intestine, liver, pancreas, bile, spleen (e.g., inflammation, ulcer, bleeding, high liver values)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

4)... the kidneys, urinary tract, reproductive organs, breast (e.g., inflammation, stone formation, cystic kidney, blood or protein secretion)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

5)... the metabolism, blood, the thyroid (e.g., diabetes, increased lipid levels, gout, anemia, leukemia, lymph nodes)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

6) ... of the brain, nervous system, psyche (e.g., multiple sclerosis, epilepsy, migraine, paralysis, fatigue syndrome, chronic pain, dizziness, anxiety disorder, depression, attention deficit syndrome, eating disorder, psychosomatic disorder, addiction, suicide attempt)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

7) ... the bones, joints, muscles, tendons or ligaments, as well as the spine, intervertebral discs (e.g., movement restrictions, misalignments, wear, inflammation, rheumatism, fibromyalgia)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

8) ... of the eyes (e.g., visual disturbances, retinal diseases, increased eye pressure, lack of vision of more than 6 diopters)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

9) ... of the ears (e.g., hearing loss, sudden deafness, ear noises, balance disorders)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

10) ... the skin or allergies (for example, inflammation, eczema, atopic dermatitis, psoriasis, house dust, pollen, pet hair, food or occupational allergy)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

11) ... such as infectious diseases, sexually transmitted diseases, tropical diseases (e.g., malaria, hepatitis, tuberculosis, borreliosis)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

12) ... the psyche (eg, depression, anxiety disorders, attention deficit syndrome, chronic fatigue syndrome, psychosomatic disorder), addiction (e.g., taking drugs, consequences of drinking alcohol)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

13) ... like benign or malignant tumors (e.g., cancer, cyst, adenoma), was there a suicide attempt or was an HIV infection detected (positive AIDS test)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

14) Is or has there been an incapacity to work or severe disability in the last 5 years?

Yes

Additional information

15) Have you been examined, advised or treated in the past 5 years on an outpatient or inpatient basis by doctors or other practitioners (e.g., Alternative Practitioner, Psychotherapist)?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

16) Have any medicines been prescribed or taken in the last 12 months?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

17) Have you undergone surgery, hospitalization or stay at a health resort, or have you had an accident, injury or poisoning over the past 10 years?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

18) Is there currently a dental treatment, the preparation or renewal of dentures, a periodontal treatment or a jaw (tooth) regulation, or have such measures been inteded or advised?

Yes

Diagnosis

Treatment from:

Treatment to:

Which treatment?

Medication, dose:

Treatment finished?

Yes

Since when:

Free of complaints?

Yes

Since when:

19) How many teeth are there missing that have not yet been replaced (except for milk and wisdom teeth, as well as teeth where the gaps have been closed by adjacent teeth)?

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