Attention: The appointment for consultation cannot take place without a completed form. If you have difficulty filling it out, please arrive 30 minutes early for your appointment so that you can fill out the medical history on the spot.

- Step 1 from 20

Dear Patient,
Dear patient,

in order to advise you well and to assist you optimally in all matters of health, we need a lot of information. Please fill out this questionnaire carefully, it contains many important questions and you may spend up to 20 minutes filling it out. Please take this time for your health.

All your health data will be processed under the strictest data protection conditions. We thank you for your trust and look forward to welcoming you to the SeegartenKlinik.

Patient code (example: K12345) - you have received this from us *.

Data protection is very important to us, therefore medical and personal data is only sent in encrypted form. For additional protection, we ask you not to enter any data that can be traced back to you. The patient code allows us to assign the sent data to your file.

Weight in kg *

Example: 95

Body height in cm *

Example: 175

1. throat - nose - ears - lungs - bronchi - respiratory organs

1.1 - Do you have breathing difficulties? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

1.2 - Are you often out of breath? (e.g. climbing stairs) *

1.3 - Is your nose often blocked? *

1.4 - Do you have impaired nasal breathing? *

Yes
No
I do not know

1.5 - Do you often use nasal spray? *

1.6 - Do you often breathe through your mouth? *

Yes
No
I do not know

1.7 - Do you suffer from asthma? *

1.8 - Do you take an asthma inhaler? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning *

Noon *

Evening *

At night *

1.9 - Do you suffer from dust mite allergy? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

1.10 - Do you suffer from any other allergies? *

Which: *

1.11 - Do you suffer from hay fever (pollinosis)? *

1.12 - Do you suffer from COPD (chronic obstructive pulmonary disease)? *

1.13 - Have you seen an otolaryngologist in the past for chronic ear, nose, or throat complaints? *

1.14 - Do you have ringing in your ears (tinnitus)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

1.15 - Have you suffered a hearing loss? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.16 - Do you often suffer from bronchitis (inflammation of the lower respiratory tract)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

1.17 - Do you often suffer from sinusitis? *

1.18 - Has inhalation therapy already been prescribed? *

1.19 - Have you had your nasal septum straightened? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.20 - Do you suffer from a nasal septum perforation (septal perforation)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

1.21 - Have the turbinates been shortened? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.22 - Has the soft palate been operated on (velopharyngoplasty)? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.23 - Was the uvula shortened? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.24 - Have the adenoids been removed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.25 - Has the base of the tongue been operated on? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.26 - Has a tongue pacemaker already been inserted? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

1.27 - Have you had sinus surgery? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

2. sleep - sleep laboratory

2.1 - Do you suffer from general sleep disorders? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

2.2 - Do you take medication to help you fall asleep? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

2.3 - Do you suffer from sleep-through disorders (arousals)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

2.4 - Do you suffer from difficulty falling asleep? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

2.5 - Do you suffer from chronic daytime sleepiness? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

2.6 - Would you describe "frequent yawning" as a problem in your case? *

2.7 - Do you suffer from narcolepsy? *

2.8 - Do you suffer from microsleep? *

Yes
No
I do not know

2.9 - Do you sleep in the prone position? *

Yes
No
I do not know

2.10 - Do you sleep in the lateral position? *

Yes
No
I do not know

2.11 - Do you sleep in the supine position? *

Yes
No
I do not know

2.12 - Do you have a special pillow? *

2.13 - Do you wake up more than once during the night? *

2.14 - Do you snore (rhonchopathy)? *

Yes
No
I do not know

2.15 - Have you ever been examined by sleep medicine on an outpatient basis (with a device at home)? (Polygraphy) *

When: *

If you cannot find out the exact date, please fill in the approximate date.

2.16 - Have you ever been examined in a sleep laboratory? (Polysomnography) *

When: *

If you cannot find out the exact date, please fill in the approximate date.

2.17 - Has a CPAP | breathing mask | been prescribed? *

2.18 - Are you using CPAP therapy? *

How many hours per night (approx): *

Why not: *

2.19 - Have different masks been tried / customized? *

2.20 - Was a mandibular advancement splint made? *

2.21 - Do you wear the protrusion splint regularly? *

Why don't you wear the protrusion splint regularly? *

3. brain - psyche - nerves

3.1 - Do you often have nightmares? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

3.2 - Do you have seemingly unfounded anxiety / panic attacks? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

3.3 - Do you take psychotropic drugs? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

3.4 - Do you have choking fears? *

3.5 - Do you suffer from depression / depressive moods? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.6 - Are you taking medication for depression? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

3.7 - Do you have migraines (cephalgias)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.8 - Do you have a headache? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.9 - Do you take medication for headaches / migraines? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

3.10 - Do you have jaw and/or facial pain? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

3.11 - Do you suffer from facial tension in the morning? *

3.12 - Do you have or have you had epileptic seizures? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.13 - Are you taking medication for epilepsy? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

3.14 - Are you forgetful (amnesiac)? *

Yes
No
I do not know

3.15 - Do you suffer from concentration disorders (cognitive dysfunction)? *

Yes
No
I do not know

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.16 - Do you suffer from chronic fatigue syndrome? *

3.17 - Have you been diagnosed with Parkinson's disease? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

3.18 - Do you suffer from multiple sclerosis? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.19 - Do you suffer from polyneuropathy? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.20 - Do you suffer from schizophrenia? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.21 - Do you suffer from dementia? *

Yes
No
I do not know

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

3.22 - Would you describe "frequent irritability" as a problem? *

3.23 - Have you received neurological / psychological / psychiatric treatment in the past? *

4. urogenital tract - prostate - gonads - bladder - kidney

4.1 - Do you suffer from loss of libido? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

4.2 - Do you suffer from erectile dysfunction? *

4.3 - Do you take testosterone? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

4.4 - Do you have a prostate condition? *

4.5 - Are you taking medication for your prostate condition? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

4.6 - Is the PSA (prostate specific antigen) level elevated? *

Yes
No
I do not know

4.7 - Do you suffer from kidney stones? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.8 - Have you had kidney stones removed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

4.9 - Do you have elevated uric acid levels? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.10 - Do you suffer from gout? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.11 - Are you taking medication for gout / elevated uric acid levels? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

4.12 - Do you suffer from bladder stones? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.13 - Do you suffer from cystitis? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.14 - Do you suffer from incontinence? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.15 - Have you had any bladder stones removed? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

4.16 - Do you suffer from frequent urination at night (nocturia)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Approximately how many times per night: *

4.17 - Have you received urological treatment in the past? *

For what reason: *

5. heart - circulation - blood vessels

5.1 - Do you often feel pressure in your chest? (angina pectoris) *

5.2 - Do you have cardiac arrhythmias (palpitations)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.3 - Do you have palpitations (tachycardia)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.4 - Have you ever suffered a heart attack? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

5.5 - Do you suffer from arteriosclerosis? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.6 - Has bypass surgery been performed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

5.7 - Are you undergoing cardiological treatment? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.8 - Do you suffer from high blood pressure (hypertension)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.9 - Do you suffer from low blood pressure (arterial hypotension)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

5.10 - Is your hypertension drug resistant? *

5.11 - Are you taking blood thinners / anticoagulant medications? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

5.12 - Are you taking medication for high blood pressure? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

5.13 - Do you often have a lowered body temperature? *

Yes
No
I do not know

5.14 - Do you often have cold feet? *

5.15 - Do you often have cold hands? *

5.16 - Do you suffer from water retention in the legs (edema)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

5.17 - Are you taking medication for edema (diuretics)? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

5.18 - Have you ever had a stroke (apoplexy)? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

5.19 - Do you suffer from dizzy spells? *

5.20 - Do you suffer from varicose veins (varicosis)? *

5.21 - Have you had varicose / spider veins treated surgically? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

How was treated: *

6. digestive organs - stomach - intestine - tract

6.1 - Are you often thirsty at night? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

6.2 - Are you often thirsty during the day? *

6.3 - Do you suffer from dry mouth (xerostomia)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

6.4 - Do you suffer from swallowing difficulties (dysphagia)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

6.5 - Do you suffer from heartburn (reflux esophagitis)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

6.6 - Do you suffer from gastritis? *

6.7 - Do you have stomach ulcers (ulcus)? *

6.8 - Are you taking medication to soothe the stomach lining? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

6.9 - Do you often have diarrhea (diarrhea)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

6.10 - Do you suffer from irritable bowel syndrome? *

6.11 - Do you suffer from inflammatory bowel disease (ulcerative colitis)? *

6.12 - Do you suffer from Crohn's disease? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

6.13 - Do you suffer from gluten intolerance (celiac disease)? *

6.14 - Do you suffer from reduced salivation? *

Yes
No
I do not know

6.15 - Have you had salivary stones? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

6.16 - Have you ever had intestinal bleeding (hematochezia)? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

6.17 - Were diverticula found in the intestinal area? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

6.18 - Are you taking medication to calm inflammation of the bowel? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

6.19 - Are you under the care of an internist regarding the gastrointestinal tract? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

6.20 - Have you ever been diagnosed with gastric ulcers (ulcers)? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

7. liver - bile

7.1 - Do you have a fatty liver (steatosis hepatis)? *

7.2 - Do you have elevated liver enzymes? *

Yes
No
I do not know

7.3 - Do you have hepatitis? *

What form of hepatitis? *

HepA
HepB
HepC

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

7.4 - Do you suffer from inflammation of the gallbladder? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

7.5 - Do you have gallstones / gallstones (cholecystolithiasis)? *

7.6 - Have the gallstones been removed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

7.7 - Has the gallbladder been removed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

7.8 - Suffering from too much cholesterol (hypercholesterolemia)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

7.9 - Are you taking medication for cholesterol? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

8. pancreas - pancreas

8.1 - Do you suffer from diabetes? *

What type? *

Type 1
Type 2

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

8.2 - Are you taking medication for blood sugar? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

8.3 - Do you inject insulin? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

8.4 - Do you suffer from insulin resistance? *

9. thyroid gland - thyroidea

9.1 - Do you have a thyroid condition? *

What ailment: *

9.2 - Leiden Sie an Hypothyreose / Hashimoto? *

9.3 - Do you take iodine tablets? *

Drug Name: *

Trade name / active ingredient

Dose (mg): *

Morning: *

Noon: *

Evening: *

Night: *

9.5 - Has your thyroid gland been removed? *

When: *

10. skin - hair

10.1 - Do you sweat very quickly (hyperhidrosis)? *

10.2 - Do you sweat more at night? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

10.3 - Do you have dry skin (xeroderma)? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

In which places: *

10.4 - Do you suffer from itchy skin (pruritus)? *

In which places: *

10.5 - Do you suffer from skin eczema? *

In which places: *

10.6 - Did you have neurodermatitis when you were young? *

10.7 - Do you currently suffer from neurodermatitis? *

Since when: *

10.8 - Do you suffer from psoriasis? *

Since when: *

10.9 - Did you have acne when you were young? *

10.10 - Do you have impure skin? *

10.11 - Do you have pimples (acne vulgaris)? *

10.12 - Do you suffer from inflammation of the skin sebaceous glands (chronic folliculitis)? *

10.13 - Do you have skin tears (rhagades, fissures)? *

10.14 - Are the corners of your mouth often inflamed? *

10.15 - Do you use skin creams? *

Which: *

Active ingredient / trade name

10.16 - Do you suffer from scaly scalp (pityriasis simplex capillitii)? *

10.17 - Do you suffer from hair loss? *

10.18 - Do you have athlete's foot (tinea pedis)? *

At what point: *

10.19 - Do you have warts? *

At what point: *

11. skeletal system - musculature - tendons - fasciae

11.1 - Do you have joint pain? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

11.2 - Do you have arthritis in the fingers (distal phalanx)? *

11.3 - Do you have a rheumatic condition? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.4 - Do you suffer from back pain? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.5 - Do you suffer from neck pain? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.6 - Do you have any complaints/pain in the spine? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Where exactly: *

11.7 - Do you stumble when you walk? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

11.8 - Do you have flat feet (pes planus)? *

Yes
No
I do not know

11.9 - Do you wear shoe inserts? *

11.10 - Have you ever had a herniated disc (prolapsus nuclei pulposi)? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.11 - Where exactly? *

Lumbar spine (LWS)
Thoracic spine (BWS)
Lumbar spine (LWS)

11.12 - Do you have any complaints of the cervical spine? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

11.13 - Have you ever had your cervical spine reduced? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.14 - Has cervicocephalic syndrome been diagnosed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.15 - Has a cervical spine syndrome been diagnosed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.16 - Has a diagnosis of BWS syndrome been made? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.17 - Has lumbar spine syndrome been diagnosed? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.18 - Do you have thoracic spine pain? *

11.19 - Do you have pain in the lumbar spine? *

11.20 - Have you had physical therapy to treat your spine? *

11.21 - Do you have pain in the shoulder area? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

11.22 - Have you already had spinal surgery? *

When: *

If you cannot find out the exact date, please fill in the approximate date.

11.23 - Do you have numb fingers? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.24 - Do you have numb legs? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.25 - Do you have other numb spots on your skin? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

In which places: *

11.26 - Do you suffer from muscular tension? *

In which places: *

11.27 - Do you suffer from fibromyalgia? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

11.28 - Do you suffer from stuck fascia? *

Where: *

11.29 - Have you ever had a torn ligament? *

Where: *

11.30 - Have you ever had a muscle fiber tear? *

Where: *

11.31 - Do you suffer from muscle cramps? *

Where: *

12. eyes - sclerae

12.1 - Do you suffer from increased intraocular pressure (glaucoma)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.2 - Are your eyes itching? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.3 - Do you have dry eyes? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.4 - Do you suffer from conjunctivitis? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.5 - Do you suffer from eye tremor (nystagmus)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.6 - Do you suffer from light sensitivity? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

12.7 - Do you suffer from visual impairment (amblyopia)? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

13. mouth - jaw - teeth

13.1 - Do you suffer from burning tongue? *

13.2 - Do you have problems biting off? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

13.3 - Do you have problems chewing? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

13.4 - Do you suffer from severe tartar formation? *

Yes
No
I do not know

13.5 - Do you suffer from periodontitis? *

Yes
No
I do not know

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

13.6 - Do your temporomandibular joints (CMD) crack? *

13.7 - Do you crunch? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

13.8 - Do you often bite your cheek and/or tongue? *

13.9 - Speech: lisp / twang? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

13.10 - Do you clench your teeth at night? *

Yes
No
I do not know

13.11 - Do you have temporomandibular joint problems? *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

13.12 - Did you receive orthodontic treatment in the past? *

When: *

14. diet - diets - weight

14.1 - Do you pay attention to your diet? *

What do you look for: *

14.2 - Do you eat too much sweets? *

14.4 - Are you following a diet? *

14.5 - Do you suffer from weight gain? *

Since when: *

If you cannot find out the exact date, please fill in the approximate date.

14.6 - Do you take nutritional supplements? *

Which: *

14.7 - Are you a vegetarian? *

14.8 - Are you vegan? *

15. habits - constitution

15.1 - Do you smoke? *

How much: *

15.2 - Do you do any sports? *

What sport: *

15.3 - Do you do yoga? *

15.4 - Do you do breathing exercises? *

16. aesthetics

16.1 - I am sometimes depressed about my appearance *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.2 - I am ashamed of the appearance of my teeth *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.3 - I don't like to see my face in the profile *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.4 - I am ashamed of the appearance of my jaw(s) *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.5 - I don't like to eat in public *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.6 - I try to cover my mouth when I meet other people *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.7 - I lack self-confidence when I'm in company *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

16.8 - I don't like to smile when I meet other people *

No
Concerns me little
Concerns me
Concerns me very much
Concerns me significantly

General anamnesis

Do you have a tumor condition? *

Which tumor condition: *

Has it been operated on? *

Chemotherapy? *

Irradiation? *

Do you suffer from HIV/AIDS? *

Do you suffer from tuberculosis? *

ALLERGIES | UNDERLYING DISEASES | MEDICATION PLAN

Bitte geben Sie hier an ob und welche sonstigen Medikamente Sie regelmäßig einnehmen.
Folgende Medikamente haben Sie bereits angegeben:

Asthma spray

✅

Sleeping pills

✅

Psychotropic drugs

✅

Antidepressants

✅

Medication for headache / migraine

✅

Medication against epilepsy

✅

Testosterone

✅

Prostate drugs

✅

Medication for gout / elevated uric acid levels

✅

Blood thinners / anticoagulant medications

✅

Medication for high blood pressure

✅

Medication against edema (diuretics)

✅

Medication to soothe the stomach lining

✅

Medication to calm the inflammation of the intestine

✅

Medication against cholesterol

✅

Medication against blood sugar

✅

Insulin

✅

Iodine tablets

✅

Do you take any other regular medications? *

Drug 1

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 2

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 3

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 4

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 5

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 6

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 7

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Enter another drug? *

Drug 8

Dose (mg)

Morning

Noon

Evening

At night

Reason for taking

Vorschau aktualisieren...

This is a preview of your medical history
Please take a moment to look over your answers and then press submit.

With your consent to participate anonymously in our studies on breathing, posture and other sequelae of sleep apnea, you help us a lot. We ask for your consent.

I understand and agree that my health data will be anonymized (i.e. coded without indication of name, address, initials or similar) and encrypted, stored on data carriers and evaluated by SeegartenKlinik for quality assurance and scientific analyses. Name, address and identifying information are kept separately by the practitioner and are only to be combined within the practice. The data will be evaluated in pseudonymized form by the epidemiological department of the SeegartenKlinik and deleted at the latest after the usual retention period of ten years.
I am aware that I can withdraw my consent to participate verbally and/or in writing at any time and without giving reasons without incurring any disadvantages.

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Sign online now *

DSGVO consent *

I consent to this website storing my submitted information so that my request can be answered.

Anamenesis - Sleep apnea consultation

Attention: The appointment for consultation cannot take place without a completed form. If you have difficulty filling it out, please arrive 30 minutes early for your appointment so that you can fill out the medical history on the spot.

1. throat - nose - ears - lungs - bronchi - respiratory organs

2. sleep - sleep laboratory

3. brain - psyche - nerves

4. urogenital tract - prostate - gonads - bladder - kidney

5. heart - circulation - blood vessels

6. digestive organs - stomach - intestine - tract

7. liver - bile

8. pancreas - pancreas

9. thyroid gland - thyroidea

10. skin - hair

11. skeletal system - musculature - tendons - fasciae

12. eyes - sclerae

13. mouth - jaw - teeth

14. diet - diets - weight

15. habits - constitution

16. aesthetics

General anamnesis

ALLERGIES | UNDERLYING DISEASES | MEDICATION PLAN

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