Form-Test: Patient Intake Form en (#5)Consent to Data ProcessingIf you want to use our Avatar Practice services, please agree that we may collect, store, and process your data. Further information about our privacy policy can be found here: [Dummylink] I agree that the information I provide will be stored to respond to my inquiry. I have read the privacy information.General InformationHave you visited our practice before? Yes NoPlease indicate how you are insured: Statutory PrivatePlease indicate your concern: Consultation Complaints Certificate of Incapacity for Work Second OpinionSymptomsPlease specify your symptoms below:Do you have fever or low temperature? Fever Low temperature Normal temperatureDo you have chills? Yes NoDo you have pain? Yes NoIn which area(s) do you have pain?Limb painJointsHead areaBackNeckAbdomen/Lower Abdomen/BladderChestArms/LegsHands/FeetDo you have symptoms in the respiratory tract or throat? Yes NoWhich respiratory or throat symptoms do you have?Stuffy noseRunny noseSneezingShortness of breathPain when breathingCoughSputumThroat discomfortNeck discomfortDo you have symptoms related to your kidneys or urinary tract? Yes NoWhich kidney/urinary symptoms do you have?Pain when urinatingVery frequent urination (large volume)Very frequent urination (small volume)Weak urine streamUrinary retentionVisible blood in urineDo you have symptoms related to your digestive tract? Yes NoWhich digestive tract symptoms do you have?HeartburnNauseaVomitingDiarrheaConstipationBlack stoolBlood in stoolPain during bowel movementsDo you have symptoms related to your sensory organs? Yes NoWhich sensory organ symptoms do you have?Visual disturbance/Eye problemsHearing loss/Ear noisesReduced smell/Taste lossImpaired sense of touchBalance disorderDo you have symptoms related to your cardiovascular system? Yes NoWhich cardiovascular symptoms do you have?Tendency to circulatory collapse/weakness/faintingBlood pressure problemsHeart palpitations/irregular heartbeatRapid heartbeatSwelling of legs/armsDo you have symptoms relating to your blood/lymph vessels? Yes NoWhich blood/lymph vessel symptoms do you have?BleedingCirculatory disorderArm swelling/blue discolorationLeg swelling/blue discolorationHeaviness in legsDo you have symptoms related to your nervous system? Yes NoWhich nervous system symptoms do you have?Concentration difficultiesSpeech disordersSeizuresTremorsMuscle weakness/paralysis (face)Muscle weakness/paralysis (arm/hand/leg/foot)Numbness/tinglingDizzinessGait instabilityNew onset urinary incontinenceNew onset fecal incontinenceDo you have psychological symptoms? Yes NoWhich psychological symptoms do you have?DepressionAnxietyCompulsionsDo you have symptoms related to your musculoskeletal system? Yes NoWhich musculoskeletal symptoms do you have?Movement restrictionsBone misalignmentDo you have symptoms related to skin and hair? Yes NoWhich symptoms related to skin and hair do you have?Rash/skin changesBurnInjuryTumorsHair lossNail changesItchy skinVisible parasite infestationDo you have symptoms related to your genital organs/sexual function? Yes NoWhich symptoms related to your genital organs/sexual function do you have?Menstrual complaintsIrregular bleedingDischargeErectile dysfunctionDo you need acute wound care? Yes NoIs the affected area a burn or another injury? Burn Another injuryWere there external influences? Yes NoWhat caused your complaints?– Select –Injury at the affected siteHead injury in the last 2 weeksInsect stingTick bite at the affected site in the last 30 daysAnimal bite at the affected siteContact with harmful substances in the last hoursOtherPlease describe the cause of your complaints:Since when have you had these complaints?– Select –TodayYesterdayThe day before yesterday3 days agoIn the last 4 to 7 daysIn the last 1 to 5 weeksLonger than 5 weeksType of consultationPlease check: Travel medicine consultation Vaccination consultation Transgender consultationWhich vaccination(s) do you want information about?Where do you want to travel?– Select –AfricaAntarcticaAsiaAustraliaEuropeNorth AmericaSouth AmericaAre there other illnesses present? Yes NoWhich illnesses are present?Are allergies or intolerances known? Yes NoWhich allergies or intolerances do you have?Do you take medications? Yes NoWhich medications do you take?Do you have additional comments:Contact detailsPlease enter your contact details below:First nameLast nameAddressStreetHouse numberCityStatePostal codeCountrySelect countryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone numberEmailSubmit
