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Dear Patient

in addition to your personal details, we also need information about your medical health condition. This is important for your treatment. Your information of course will be kept secret according to medical confidentiality data protection.

Personal Details


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Old-age pension
Body Weight /-height: Gender: *

Health insurance:

Demo Praxis

Infectious Diseases:

- Hepatitis
- Tuberculosis

Vascular diseases:

- Varicose veins
- Thrombosis
- Lymphedema
- Other

Complaints of the vegetative / autonomous nervous system:

- Dizziness
- Tinnitus
- Fatigue
- Indigestion
- Heartirror / -stumble
- Sleep disorders
- Concentration
- Reptile freezing or sweating
- Difficulties swallowing

Current complaints:

- Did you have an accident?
- Do you have pain in shoulder?
- Do you have pain in the elbow?
- Do you have pain in hand?
- Do you have pain in hip?
- Do you have pain in the knee?
- Do you have pain in the ankle / foot?
- Do you have spinal pain?
- Other current complaints

Heart and circulatory Diseases:

- Heart failure (insufficiency)
- Cardiovascular disease
- Arrhythmia
- Heart valve replacement
- Pacemaker available
- Heart attack
- High blood pressure

Neurological / psychiatric diseases:

- Stroke / apoplex
- Epilepsy
- Parkinson
- Depression
- Panic attacks

Allergies / Incompatibilities:

- Allergies / Incompatibilities


- Are you a trauma / injury remembered? (e.g., Stuchbeinprellung, skull brain trauma, fall on the face, ...)

Metabolic Diseases:

- Diabetes
- Gastrointestinal Diseases
- Hyperthyroidism
- Hypothyroidism
- Osteoporosis

Tumor diseases / cancer:

- Tumor / cancer
- Irradiation
- Chemotherapy

Operational interventions:

- Did you have operational interventions of any kind?
- Were your teeth removed? (e.g., wisdom teeth, molars, canines as a child, ..)
- Have you ever had a root treatment?

Lung and Kidney Diseases:

- Asthma / COPD
- Renal failure
- Others


- Current pregnancy?
- Green Star
- Do you smoke?
- Others
- Regular drugs? If yes, which?

In our own interest:

- How did you hear about our practice?

Privacy policy

If you send us your details using the online anamnesis form, they will be stored by us, including the contact details you provided, for the purpose of processing your request and in the event of your treatment. This information is purely voluntary and is subject to medical confidentiality. They will not be passed on to third parties without your consent. By sending the form, you give your consent, which you can revoke at any time and for the future. Learn more about this in our privacy policy. DSGVO

I have the right to comprehensive information about the data stored about me at any time. I can request the correction, deletion and blocking of my personal data from a doctor and his cooperation partners at any time, provided there are no other legal regulations to the contrary. I am aware that I can revoke the declaration in whole or in part for the future at any time without giving reasons.


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× Signature of the patient / guardian

Demo Praxis
All data given here will be transmitted directly to the practice in encrypted form. The practice collects and processes the data in accordance with data protection regulations.

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