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Questionnaire

regarding in-patient treatment at Klinik am Steigerwald

Sender

Last Name
Date of Birth
First Name
Street
ZIP Code, City, Country
Fax
Telephone, private
eMail
Telephone, at work/cell phone
Health Insurance
I prefer to schedule my in-patient treatment at the following time (please indicate month and year):
I require a
Wheel Chair
Walker

I prefer a
Single Room
Double Room

I need assistance with the following daily activities:


To
Klinik am Steigerwald
Waldesruh
D - 97447 Gerolzhofen



How did you learn about the clinic:
In order to medically evaluate the outcome of your treatment in our clinic we ask you to provide the following information about yourself and your health complaints. Please provide us with information about your preexisting conditions, the treatments you have received to date, and your current medication. The information given serves as a first basis for our evaluation regarding the success of your treatment.
We will contact you shortly
upon receipt of this web form.
 
I am interested in a treatment with Chinese Medicine primarily because of the following complaint(s):
My diagnoses: Since:
I am pregnant  
 
Further complaints Since:
Operations, clinical in-house treatments, and other therapies you received to date: Date:
My current medication consists of: (in addition to prescribed medication, please include hormonal supplements e.g.contraceptives, laxatives, sedatives, and barbiturates) Since:
I smoke cigarettes per day
   
Your data is treated with the utmost confidentiality. Thank You.
We will contact you shortly upon receipt of this web form.
Von der Klinik am Steigerwald auszufüllen:
 
 
 
 
Medikamentenberatung (z.B.: Dauermedikation, Pille, Genussmittel, ...)
 
Versicherungsrelevante med. Informationen: