Pre-appointment questionnaire

Pre-visit Questionnaire

To prepare your appointment well, we ask you for a few details about your medical history. The data is transmitted encrypted and processed only in connection with your appointment.

Fields marked with * are required.

Salutation

First name

Last name

Date of birth

Phone number

Reason for your visit

Height (cm)

Weight (kg)

Pre-existing conditions

Long-term medication

Allergies / intolerances

Surgeries / hospital stays

Smoker

YesNo

Alcohol

YesNo

Pregnancy

YesNo

Other notes (optional)

I consent to the processing of my data per the Privacy Policy.