Medical Practice Dr. med. Leo Najman: Medical history

If you have never been to our practice before, we kindly ask you to answer the following questions about your medical history. You may either print it out and hand it to our staff at your first visit or simply send it to us online at the touch of a button. This saves both you and us time and ensures that you receive the best treatment possible.

Alternatively, you can also fill out the medical history form during your first visit at our practice if you prefer or are unable to send it to us beforehand.

Name *

Date of birth (dd.mm.yyyy) *

Male

Female

Street *

Zip Code *, City *

Occupation *

Employer *

Telephone (daytime) *

Mobile

E-Mail *

Social Security Number *

ID Card Number / Passport Number

Please indicate which children’s diseases you had

Measles / Rubeola

German measles / Rubella

Chicken pox / Varicella

Mumps

Scarlet fever / Scarlatina

Operations?

Appendix

Tonsillectomy

Others

General medical history?

High blood pressure / Hypertension

Diabetes

Gastric ailments

Tumour ailments

Kidney ailments

Skin disease

Lipometabolism disorders

Uric acid metabolic disorders / Gout

Joint rheumatism

BCG-Tuberculosis

AIDS

Inflammation of the liver

Asthma

Heart condition / Cardiovascular disorders

Mental & psychic illness

Seizure disorders

Others

Allergies against?

Penicillin

Aspirin acetyl acid

Pollen

Animal hair

Acarians

Foodstuff * (if yes, please specify below)

Metals

Others

Family medical history

High blood pressure / Hypertension

Diabetes

Lipometabolism disorders

High blood pressure / Hypertension

Asthma

Cancer * (if yes, please specify below)

Others

Vegetative medical history

Thirst * Normal, Increased

Appetite * Normal, Increased

Dejection * Normal, Increased *

* if not normal, Diarrhoea, Constipation

* if diarrhoea, with blood with mucus

* how often a day?

Urination * Normal, Increased *

* if not normal, burning sensation initiation problems
more than 1-2 times per night

Weight * Stable, Not stable *

* if not stable, Increase, Decrease

kilograms in months

I often feel cold.

I often feel hot.

I sweat more than normal.

I often have headaches.

Smoker? * No, Yes * (if yes, please specify below)

How many cigarettes a day?

Alcohol? * No, Yes * (if yes, please specify below)

* Daily, Occasionally

* What?

* How much (in litres per week)?

Female patients

Pregnancy? No, Yes

Births? No, Yes

Birth control pill? No, Yes

Monthly menstruation

Regularly? No, Yes

Painful? No, Yes

All patients

Do you regularly take medication? * No, Yes * (if yes, please specify below)

* Type of medication?

Body height (cm) *

Body weight (kg) *

I have immunisation protection through vaccination against

Tetanus

Diphtheria

Polio

BCG-Tuberculosis

Mumps

Hepatitis A

Hepatitis B

German measles / Rubella

I wear glasses / contact lenses * No, Yes * (if yes, please specify below)

* Dioptres Right, Left

I am currently free of complaints * Yes, No * (if no, please specify below)

* Current complaints (with time specification)

Please carry out the following specific checks-ups

Gastric

Heart & lung / Cardio-pulmonary

Stress electrocardiogram (cardio test while riding on a bicycle)

AIDS test

Please recommend a renowned medical colleague

Dentist

Gynaecologist

Otorhinolaryngologist (Ear, nose and throat specialist)

Neurologist

Orthopaedist

Dermatologist

Paediatrician

Please renew my vaccination immunisation * No, Yes

I place special emphasis on

I am insured as follows: * Privately, Social Health Insurance

Insurance *

My insurance covers all expenses for

Check-Ups * No, Yes, up to a maximum of Euro

Treatments * No, Yes, up to a maximum of Euro

Please tell us how you came to know of our practice

Yellow Pages / Telephone book

Internet

Personal recommendation by

Others

Safety query *

In order to avoid spam, please fill in the answer of the following simple maths question:

Result of 4 + 2

* required

Hide Images