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) ________________________________________ _________________________________________
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5. Stool habits 6. Urination □ regular, no problems □ without complication □ constipated □ high frequency □Diarrhe □ at night / how often: ________
7. Sleep 8. Weight changes over the last 12 month □ untroubled □trouble falling asleep □trouble sleeping through 9. Allergies 10. Last cancer screening / follow-up care
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11. Nicotin consumption 12. Alcohol consumption □ No-smoker □ never □ Smoker / how many: ________ □ rarely □ regularly / how much: ________
13. Care at home 14. Civil status □ live alone □ married □ secured □ single □ Stairs / number:______ □ widowed □ Elevator □ Children / number: ________
15. Work □ Job: _______________________________________________________________ □ Pensioner 16. Additional remarks
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- KOBAYASHI ZEIN DP - Zein is a major component of corn proteins, called a prolamine soluble in aqueous ethanol. Zein is extracted from gluten meal separated under corn starch production. The acquisition of deodorized and decolourised zein is attained by Kobayashi’s method. It is called “KOBAYASHI ZEIN DP”. We supply “KOBAYASHI ZEIN DP” to be used for food processing, cosmeti
Clinik Dr. Baumstark