Hospital admittance form

name:
address:
e-mail:

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.

A. family media-medical history

Did the following diseases occur in your family?
Un-sharp Syndrome
Nightblindness
Dissolve Syndrome

B. media allergies

Are you allergic (sensitive) to:
software?
RGB mode?
s-video?
undo or redo?

C. ailments

Please describe in detail where the symptoms appear:
head
torso
legs

D.What is the intensity of these symptoms?

weak
strong
measurement (if known):

E. secondary symptoms

Do you have any other ailment?

© BRGMKMEDA . Body Research Group Markus Käch für medial-medizinische Datenerfassung und Auswertung GmbH, Köln 1994