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Anamnese (englisch) Krankengeschichte
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Dr. med. Margarita Kiewski & Dr. med. Wolfgang Hirsch
Tel: 261 2043 www.praxis-hirsch-kiewski.de
e-mail adress: ____________________ @
o name: o Are you on medication? pills/tablets? â–ˇ Yes â–ˇ No
Which?
o height: cm urination normal? â–ˇ Yes â–ˇ No
o weight: kg stool normal? â–ˇ Yes â–ˇ No
o What is your profession / work?
o What is the reason for your visit? Do you have any allergies?
â–ˇ pain â–ˇ normal check up â–ˇ smear â–ˇ pregnancy Which?
o When was your last visit to a gynaecologist? o How do you prevent ? â–ˇ condom â–ˇ nothing
o When was your last cancer prevention check? â–ˇ coil(Which? How long have you had your coil?)
â–ˇ pill (name of the pill)
o How old were you when you got the first period? ____ years
o When was your last bleeding?/period? (1st day)
o Cycle interval (days): ____ days o Have you had rubellos / measles or chicken pox? â–ˇ Yes â–ˇ No
o Is your period â–ˇ weak? â–ˇ Normal? â–ˇ Strong?
o Is your bleeding painful? â–ˇ Yes â–ˇ No o Do you smoke? â–ˇ Yes â–ˇ No How many cigarettes per day? ____
o Age when menopause began? ____ years o Are you interested in following main point?
o Do you have children? â–ˇ Yes â–ˇ No
o When was the child born (â–ˇ boy â–ˇ girl?) o year: â–ˇ extensive prevention
o Have you had miscarriges? â–ˇ Yes â–ˇ No â–ˇ infectionstest
o Have you had abortions? â–ˇ Yes â–ˇ No â–ˇ smear/blood-test
o Have you had any operations? â–ˇ Yes â–ˇ No â–ˇ vaccination
o Have you had gynecological operations? When? â–ˇ traditional Chinese medicine
â–ˇ child wish
o Do you have the following: â–ˇ high blood pressure â–ˇ intimate surgery
â–ˇ blood clot â–ˇ prevention advice
â–ˇ circulation / problems with your heart
â–ˇ headache
o Illnes s in your family: â–ˇ diabetes For further questions please do not hesitate to contact us!
â–ˇ thrombosis
â–ˇ high blood pressure Tel: 030 261 2043 info@praxis-hirsch-kiewski.de
â–ˇ cancer