You require the services of the electronic hospital because of illness,
prevention or other reasons. Before every preliminary examination the doctor
needs to know the patient's media-medical history. Please use the waiting
period to fill out this form carefully and attentively.
Did the following diseases occur in your family?
Are you allergic (sensitive) to:
undo or redo?
Please describe in detail where the symptoms appear:
measurement (if known):
Do you have any other ailment?
© BRGMKMEDA . Body Research Group Markus Käch
für medial-medizinische Datenerfassung und Auswertung GmbH, Köln