Kurz-Anamnese englisch

After submitting, you will receive a confirmation email. Your information will only be transmitted to the practice after you click the confirmation link. The link is valid for 48 hours.

Please note: Completing this questionnaire does not replace booking an appointment. Please also book an appointment for new patients and provide your insurance details. Otherwise, the questionnaire will be deleted after a short while and will not be processed.

Please fill in the following information completely. Thank you for your support.

Mit freundlichen Grüßen ihr Praxisteam MVZ Kreuzberg | www.mvz-kreuzberg.de

Email address

First name
Last name
Date of birth
Type of insurance
Health insurance provider
Insurance member number
Health insurance fund identifier / provider institution number (IK number)
Usually 9 digits and often starts with 10. Not the identifier of the health insurance card.
Valid until / card expiry date
What is your phone number (mobile or landline)?
What is your email address?
Do you have a Doctolib account?
YesNo
What is your postal address (street, postcode, city)?
Required for billing and documents.
Do you have a general practitioner?
YesNo
How tall are you? (e.g. 175 cm)
How much do you weigh? (e.g. 70 kg)
What is your occupation?
Do you suffer from any chronic illnesses? If yes, which ones?
Are there any known hereditary diseases in your family?
Do you have any allergies or intolerances?
Do you take any medication regularly? If yes, which ones?
Do you smoke?
YesNo
Do you drink alcohol?
YesNo
Do you take any other substances?
Is your vaccination status known?
YesNo