Start anamnesis now Name Date of birth E-mail address Telephone number Profession What is your main concern? How long have the symptoms been present? Previous diagnoses or therapies? Was there a trigger or a change in lifestyle? Do you currently have a natural cycle? Yes No If no: No period Hormonal contraception Menopause Other Cycle regular irregular strong/weak painful PMS Contraception no pill IUD condoms natural methods Miscellaneous Do you currently want to have children? Yes No In planning Do you have children? Yes No Were there any miscarriages, hormone treatments or diagnostics? Has there been a change in weight? Yes No If so, how much and in what period of time? Cravings, tiredness after eating, concentration problems? Nutrition balanced high-carb vegetarian/vegan irregular Movement regularly occasionally rarely Sleep quality good restless Sleep problems Stress level(1-10) Complaints & symptoms Cycle problems PMS Acne Hair loss Weight gain Exhaustion Loss of libido Sleep disturbance Digestive problems Hot flushes Depression/anxiety Pain Thyroid disease Other Known diseases Current medication or hormones Allergies or intolerances Verdauungsprobleme (Blähungen, Verstopfung, Durchfall)? Ja Nein Antibiotika in den letzten 12 Monaten? Ja Nein Nehmen Sie Nahrungsergänzungsmittel ein? Welche? Wurde ein Mangel festgestellt? Ja Nein Was möchten Sie mir sonst noch mitteilen? Ich bin einverstanden mit der Datenverarbeitung zur Online-Sprechstunde. Kurzantwort Digitale Unterschrift (Name eingeben) I have been informed that the medical consultation and treatment by the doctor will take place as part of an online appointment. In the process, personal health data may be transmitted and processed digitally. Send
