Patient Data Sheet

(Please Print All Information)

$$PATIENT-P_NAME$$ $$PATIENT-P_TITEL$$	$$PATIENT-P_GEBOREN$$
Family Name, First Name (Patient)	Date of Birth, Sex: m f
$$PATIENT-P_STRASSE$$
$$PATIENT-P_PLZ$$ $$PATIENT-P_ORT$$
Street Address
Zip, City, Country
$$PATIENT-P_TELEFON$$
Home Phone / Cell Phone	Work Phone
$$PATIENT-P_EMAIL$$
E-Mail	Profession
Insurance Company Name
Reffering Physician – Name, Address, Phone
Family Doctor – Name, Address, Phone

If insured person is differing from patient mentioned above please fill in:

Family Name, First Name (insured person)	Date of Birth

Street Address	Zip, City, Country

Consent of treatment of a Minor

If patient is under the age of 18, parental consent for treatment (except acute ache) of a min is required:

Date	Parent / Legal Guardian Signature

Please answer the following questions regarding your state of health as exactly as possible:

State of Health	Please mark	Further Information
Cardiovascular Diseases:
Hypertension	Yes	No
Hypotension	Yes	No
Valvular Heart Disease/Defect
Endocarditis	Yes	No
Heart Surgery	Yes	No
Pacemaker	Yes	No

Infectious Diseases:
AIDS
Yes
Hepatitis
Yes
Tuberculosis	Yes	No
other:

Allergies / Intolerances:	Please mark	Further Information
Local Anesthetics	Yes	No
Analgesics	Yes	No
Antibiotics	Yes	No
other:
Further Diseases:
Coagulation Diseases	Yes	No
Asthma	Yes	No
Lung Diseases	Yes	No
Thyroid Diseases	Yes	No
Rheumatism	Yes	No
Epilepsy	Yes	No
Diabetes	Yes	No
Nephropathy	Yes	No
Fainting	Yes	No
orther:

General Data:
Drug Addiction	Yes	No
Drinking of alcoholic beverages	Yes	No	If yes, seldom often regularly
Smoker	Yes	No	If yes, 0-10 over 10 cigarettes/day
Regular Medication/Drugs	Yes	No	If yes, since when / Name:
X-Rays taken before	Yes	No	If yes, Date / Body Parts:
Gravidity / Pregnancy	Yes	No	If yes, what month:

Important Information:

All information is subject to professional medical secrecy and to the regulations on the protection of the privacy of personal data and treated strictly confidential.

I agree to those data being saved and processed electronically.

-	I engage myself to inform you immediately about all changes occurring during the period of treatment.

-	I engage myself to keep agreed appointments or to chancel them at least 2 days in advance, otherwise occurring costs can be invoiced.

-	I certify with my signature that I have read and understand all above printed information.

Date	Patient Signature and Parent / Legal Guardian Signature

Erfassungsbogen $$PRAXIS-NAME$$	$$DATUM-AKTUELL$$

Patient: $$PATIENT-P_TITEL$$ $$PATIENT-P_VORNAME$$ $$PATIENT-P_ZUSATZ$$$$PATIENT-P_NAME$$

$$DMS-BARCODEVERTIKAL$$

Anamnese KFO englisch

KFO

KFO; Anamnese/Befund

Computer konkret AG

2009-03-17

Admin

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