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Patient questionnaire online

Dear patient, please take about 10 minutes to fill in this questionnaire carefully. We will go through your answers with you at your appointment. All information is subject to medical confidentiality and is transmitted to our practice in encrypted form.

Please note: only our doctors speak English; our practice team speaks German.

Fields marked * are required. Your entries are not saved in between – please do not close the page before submitting.

1Details
2Health
3Lifestyle
4Signature

Website

1. Personal details

Surname *

First name *

Date of birth *

Sex *

malefemalediverse

Street, house number *

Postcode *

Town *

Mobile / phone number *

Occupation

Health insurance

I am *

insured with a statutory health insurer (GKV)privately insured / entitled to Beihilfeself-paying

Health insurance company

Previous care

Previous family doctor (GP)

Emergency contact (name, phone)

Step 1 of 4

2. Illnesses, medication, allergies

Previous and current illnesses

Please answer every question with Yes or No.

Heart and circulation

High blood pressure

YesNo

Heart disease (e.g. heart attack, heart failure, arrhythmia)

YesNo

Stroke

YesNo

High blood lipids

YesNo

Thrombosis / pulmonary embolism

YesNo

Poor circulation in the legs

YesNo

Metabolism and organs

Diabetes

YesNo

Thyroid disease

YesNo

Kidney disease

YesNo

Liver disease

YesNo

Gastrointestinal disease

YesNo

Lung disease (e.g. asthma, COPD)

YesNo

Other conditions

Cancer

YesNo

Neurological disease (e.g. epilepsy, Parkinson’s)

YesNo

Mental health condition (e.g. depression, anxiety disorder)

YesNo

Blood clotting disorder

YesNo

Chronic infectious disease (e.g. hepatitis B/C, HIV)

YesNo

Skin or eye disease

YesNo

Details / other conditions

Operations / accidents (with year)

Medication

Please also include blood thinners, injections, sprays, patches, the contraceptive pill and supplements.

Do you take medication regularly? *

YesNo, no medication

I have a medication list and will bring it to my appointment.

My medication

MedicationStrengthmormidevenight

Allergies and intolerances

Do you have any allergies or intolerances? *

YesNo

Which? (especially to medication) *

Step 2 of 4

3. Lifestyle, screening and family

Body and lifestyle

Height (cm)

Weight (kg)

Sport / exercise (what, how often?)

Smoking

NeverYesFormerly

Cigarettes per day

For how many years?

Stopped in (year)

Alcohol

NoOccasionallyRegularly

Roughly how much? (e.g. 2 glasses of wine per week)

Are you currently pregnant or breastfeeding?

NoPregnantBreastfeeding

Other treatment

Are you seeing a specialist?

YesNo

With whom? (specialty, practice)

Chronic disease programme (DMP)

CHDDiabetesAsthmaCOPDother

Screening and examinations

Approximate dates (month/year) are fine. If you don’t know, simply leave the field empty.

Last check-up (from age 35)

Last colonoscopy

Last ECG / exercise ECG

Cardiac catheter (when?)

Last 24-hour blood pressure test

Last eye examination

Last tetanus vaccination

Vaccination record available?

YesNo

Family history

Parents, siblings, grandparents

Heart attackStrokeDiabetesHigh blood pressureCancerPoor circulation in the legsThrombosisDementianone known

Details (who, at what age, which type of cancer)

Living situation

Marital status

In a relationshipSingleWidowed

Children (number)

Care level (Pflegegrad)?

No12345

Is there anything else important we should know?

Step 3 of 4

4. Consent and signature

Reminders for check-ups and vaccinations

May we remind you about due check-ups and vaccinations?

NoYes

How may we remind you?

PhoneSMSEmail

Data protection and online transmission

Data protection. We need your information for your treatment. We store it in your patient record; it is subject to medical confidentiality and will only be passed on to third parties with your consent or on a legal basis. The legal basis is Art. 9(2)(h) GDPR in connection with the treatment contract and, for the online transmission, your consent (Art. 9(2)(a) GDPR). Further information can be found in our privacy policy (German).

Online transmission. Your information is transmitted to our web server in encrypted form (HTTPS), converted there into a PDF without being stored, and sent to the practice as an end-to-end encrypted email (S/MIME). It is only decrypted at the practice and transferred to your patient record.

I have filled in this questionnaire completely and correctly to the best of my knowledge. I will inform the practice of any changes. *

I consent to Praxis Sennewald (joint practice of Dr. med. Rasmus Sennewald and Dr. med. Julia Sennewald) processing my information, including my health data, for my treatment and to this form being transmitted to the practice in encrypted form via the website. I can withdraw this consent at any time with effect for the future. *

Signature

Town *

Signature of patient (or legal representative) *

Sign here with your finger or the mouse

For minors, a parent or guardian signs.

Step 4 of 4

Thank you!

Your questionnaire has been received securely. We will go through your answers with you at your appointment.

Reference number:

Please bring your health insurance card and, if available, your medication list and vaccination record to your appointment.

Please sign here – Tip: turn your phone sideways for more space.

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