Clinik Dr. Baumstark

Questionnaire I
For admission – Medical history
Dear Patient,
In the course of your examination at admission, you will be asked questions about previous
illnesses, surgical procedures and accidents. We would ask you to complete the questionnaire
calmly and completely and to return it to us or bring it with you. That will ensure that sufficient
time is available for the physician to discuss your personal problems with you.
It would be particularly helpful for both yourself and the physician at Dr. Baumstark Clinic if you
could bring additional reports and diagnostic findings (hospital discharge reports, X-Rays and ECG
findings, etc.) with you. We will, of course, return this documentation to you as soon as your
medical rehabilitation treatment is complete.
Name:_______________________________ First Name:___________________________________
1. Family medical history
(e.g. diabetes mellitus, cancer, cardiac disease, strokes)
2. Diagnosis of your own primary illnesses in chronological order
(e.g. 1980: bronchial asthma, 1991: high blood pressure)
3. Important surgical procedures that you have undergone in chronological order
(e.g. 1995: TR right hip because of arthritis)

4. Regular medication prescribed by your physician, strength and dosage
(e.g. Bisoprolol 5mg, 2 x daily)
________________________________________ _________________________________________ ________________________________________ _________________________________________
5. Stool habits

6. Urination
regular, no problems
without complication
high frequency
at night / how often: ________

7. Sleep
8. Weight changes over the last 12 month
trouble falling asleep
trouble sleeping through
9. Allergies
10. Last cancer screening / follow-up care
11. Nicotin consumption

12. Alcohol consumption
Smoker / how many: ________
regularly / how much: ________

13. Care at home
14. Civil status
live alone
Stairs / number:______
Children / number: ________

15. Work
Job: _______________________________________________________________
16. Additional remarks




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