Medical history form

Step 1

Personal data

Basic information for identification and contact by the practice.

Required fields are marked with an asterisk.

First name *

Last name *

Date of birth *

Gender

Insurance

Phone *

Email *

Street and house number

Postal code

City

Step 2

Reason for appointment

Please tell us why you would like to contact the practice.

Medical classification

Treatment area *

Appointment type *

Main concern *

Since when have the symptoms existed?

Current limitations

Step 3

Medical history

Relevant previous illnesses and treatments help us prepare your appointment.

Previous findings

Known diagnoses

Depression Anxiety disorder ADHD Epilepsy Migraine Stroke Polyneuropathy Sleep apnea

Previous treatments / therapies

Hospital stays or rehabilitation

Family medical history

Step 4

Medication and allergies

Please enter current medication and known intolerances.

Medical safety

Regular medication

Allergies / intolerances

Nicotine, alcohol or other substances

Step 5

Documents

Optional documents can help prepare your appointment.

Optional

Findings, referral or previous reports

PDF, JPG or PNG. You can select multiple files.

No file selectedOptional

Step 6

Consent and confirmation

Your information will only be submitted after your confirmation.

Final confirmation

Data protection notice

Your data will be used to process the medical history form and prepare your appointment. Please do not use this form for emergencies.

I have read the Privacy Policy and consent to the processing of my information for appointment preparation.

I confirm that my information is complete and correct to the best of my knowledge.

Step 7

Review and send

Please check your information before submitting the form.

Final check

Neurology

Psychiatry

Psychotherapy

Sleep Medicine

Personal data

Reason for appointment

Medical history

Medication and allergies

Documents

Consent and confirmation

Review and send

Medical history form

Personal data

Reason for appointment

Medical history

Medication and allergies

Documents

Consent and confirmation

Review and send

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