Anmeldebogen Erwachsene Family (Englisch)

By completing this form, you help us better understand the reasons for your visit and the possible causes of your symptoms. Your answers provide us with important information for planning your therapy. All data will be treated with the highest confidentiality and used solely for therapeutic purposes.

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Name *

Date of birth *

Address *

Adresse Zeile 1

Ort

Region

Postleitzahl

AfghanistanAlbanienAlgerienAmerikanisch-SamoaAmerikanische JungferninselnAndorraAngolaAnguillaAntarktikaAntigua und BarbudaArgentinienArmenienArubaAserbaidschanAustralienBahamasBahrainBangladeshBarbadosBelgienBelizeBeninBermudaBhutanBolivien (Plurinationaler Staat)Bonaire, Sint Eustatius und SabaBosnien und HerzegowinaBotswanaBouvetinselBrasilienBritische JungferninselnBritisches Territorium im Indischen OzeanBrunei DarussalamBulgarienBurkina FasoBurundiCabo VerdeChileChinaCookinselnCosta RicaCuraçaoCôte d'IvoireDeutschlandDjiboutiDominicaDominikanische RepublikDänemarkEcuadorEl SalvadorEritreaEstlandEswatini (Königreich)Falklandinseln (Malwinen)FidschiFinnlandFrankreichFranzösisch-GuayanaFranzösisch-PolynesienFranzösische Süd- und AntarktisgebieteFäröer-InselnGabunGambiaGeorgiaGhanaGibraltarGrenadaGriechenlandGrönlandGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard- und McDonald-InselnHondurasHongkongIndienIndonesienIrakIran (Islamische Republik)IrlandIslandIsle of ManIsraelItalienJamaikaJapanJemenJerseyJordanienKaimaninselnKambodschaKamerunKanadaKasachstanKatarKeniaKirgistanKiribatiKokosinseln (Keelinginseln)KolumbienKomorenKongo (Demokratische Republik)Kongo (Republik)Korea (Demokratische Volksrepublik)Korea (Republik)KosovoKroatienKubaKuwaitLaos (Demokratische Volksrepublik)LesothoLettlandLibanonLiberiaLibyenLiechtensteinLitauenLuxemburgMacauMadagaskarMalawiMalaysiaMaledivenMaliMaltaMarokkoMarshall-InselnMartiniqueMauretanienMauritiusMayotteMexikoMikronesienMoldau (Republik)MonacoMongoleiMontenegroMontserratMosambikMyanmarNamibiaNauruNepalNeukaledonienNeuseelandNicaraguaNiederlandeNigerNigeriaNiueNordmazedonien (Republik)NorfolkinselNorwegenNördliche MarianenOmanOsttimorPakistanPalauPalästina (Staat)PanamaPapua-NeuguineaParaguayPeruPhilippinenPitcairninselnPolenPortugalPuerto RicoRuandaRumänienRusslandRéunionSaint-BarthélemySaint-Pierre und MiquelonSalomonenSambiaSamoaSan MarinoSaudi-ArabienSchwedenSchweizSenegalSerbienSeychellenSierra LeoneSimbabweSingapurSint MaartenSlowakeiSlowenienSomaliaSpanienSpitzbergenSri LankaSt. Helena, Ascension und Tristan da CunhaSt. Kitts und NevisSt. LuciaSt. Martin (französisch)St. Vincent und die GrenadinenSudanSurinamSyrien (Arabische Republik)São Tomé und PríncipeSüdafrikaSüdgeorgien und die Südlichen SandwichinselnSüdsudanTadschikistanTaiwan, Republik ChinaTansania (Vereinigte Republik)ThailandTogoTokelauTongaTrinidad und TobagoTschadTschechische RepublikTunesienTurkmenistanTurks- und CaicosinselnTuvaluTürkeiUSAUgandaUkraineUngarnUnited States Minor Outlying IslandsUruguayUsbekistanVanuatuVatikanstadt (Staat)Venezuela (Bolivarische Republik)Vereinigte Arabische EmirateVereinigtes Königreich von Großbritannien und NordirlandVietnamWallis und FutunaWeihnachtsinselWeißrusslandWestsaharaZentralafrikanische RepublikZypernÄgyptenÄquatorialguineaÄthopienÅlandinselnÖsterreichLand

Mobile *

E-Mail *

Insurance *

Current Occupation *

Hobbies/physical activities *

Are you currently receiving treatment in any of the following areas? *

• General Medicine
• Orthopedics
• Osteopathy
• Dentist
• Psychology
• Other
• No

symptoms have surgeries

What?

Have you ever been diagnosed with any of the following conditions? *

• Musculoskeletal system (Bone fractures, Arthritis, etc.)
• Neurological (Paralysis, Stroke, etc.)
• Autoimmune diseases (MS, Rheumatism, etc.)
• Cardiovascular (Heart attack, Heart failure, etc.)
• Pulmonary System (Asthma, COPD, etc.)
• Metabolic Diseases (Diabetes, etc.)
• Infectious Diseases (Shingles, Hepatitis, etc.)
• Other
• No

What?

Please list any allergies you have had: *

• Medication
• Latex
• Tapes/Band-Aids
• Other
• None

What?

Please list any surgeries you have had (type and date): *

• Joint replacement
• Spinal surgery
• Tumor surgery
• C-Section
• Other
• None

What and when?

Which of the following medications have you taken in the past week: *

• Painkillers
• Anti-inflammatories
• Anticoagulants
• Muscle relaxants
• Psychotrophic medication
• Other
• None

What and was it prescribed?

What symptoms or reasons brought you to our practice? *

• Pain
• Other

What?

Please rate your pain on a scale from 0 (no pain) to 10 (worst imaginable pain): *

Bewerte mit 1 von 10Bewerte mit 2 von 10Bewerte mit 3 von 10Bewerte mit 4 von 10Bewerte mit 5 von 10Bewerte mit 6 von 10Bewerte mit 7 von 10Bewerte mit 8 von 10Bewerte mit 9 von 10Bewerte mit 10 von 10

Pain quality: if possible, describe the nature of you pain *

• superficial (ex. Sharp/stinging)
• deep (ex. pounding/dull)
• neuropathic (ex. Burning-electrifying/shooting)
• Other

Other:

Where are you currently experiencing pain?

Please describe as precisely as possible: The exact location of the pain (e.g., lower back, right shoulder, left knee, etc.) Whether the pain originates from this spot Whether and where the pain radiates (e.g., “radiates from the neck into the shoulder”) Optional: Since when, how severe (scale 1–10), how often (constant, under strain, etc.)

Do you experience symptoms other than pain? *

• Muscle weakness/instability
• Uncertainty while walking
• Numbness
• Swelling/Edema
• Jaw (cracking, crunching)
• Stiffness/Blockage
• Dizziness
• Tinnitus
• Insomnia
• Incontinence
• Other
• No

What?

How long have you been experiencing these symptoms? *

• less than 1 month
• 1 month to ½ a year
• ½ to 1 year
• more than 1 year

Was there a specific cause?

• Yes
• No

Which?

Do these symptoms change depending on: *

• Rest
• Movement
• Time of day
• Stress or relaxation
• Other

Other

How did you find us?

• Google
• Physician
• Recommendation/Family and friends
• Other

Other

My contact data may be used in accordance with Art. 7 Abs. 1 DSGVO for marketing purposes. *

• Ja

Signature

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For patients with public health insurance:

I acknowledge that patients with public health insurance are required to pay an additional co-payment (10 € per prescription plus 10% of the prescription value). If you are exempt from this fee, please provide your exemption certificate.

I had physical therapy in the past 12 weeks: □ yes □ no

I consent to the processing, storage, and transmission of my data to the Center Optica Dr. Güldener GmbH for billing purposes.

For patients with private health insurance:

In the fee arrangement you will be informed about the renumeration rates. Patients are obliged to pay the fee for the services provided, regardless whether your private health insurance or other financial aid services will pay parts, the entire fee or none at all.

Privacy policy

I understand that my data is being used for following reasons:

– Ongoing care and communication

– Fulfilling the treatment contract

– Billing (insurance, billing services, or self-pay)

– Therapeutic documentation

– Medical correspondence with my referring physician(s)

I understand that my data may be shared with the relevant insurance companies, medical offices, and billing services for the purposes above. I may revoke this consent in part or in full at any time.

Cancellation/ Default fee

Since we exclusively work with appointments, it is very important that you cancel appointments at least 24 hours prior, if you are not able to come.

Please note that in case of late cancellations or missed appointments, a cancellation fee will apply, as we are unable to reassign the reserved time slot (§§ 615, 293 ff. BGB – German Civil Code).