Anamnesis

Anamnesis
Dr.med. S. Jahn
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Surname:
____________________
First name: ____________________
Date of birth: ____________________
personal phone number: _________________
Reason for visit:
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preventative care
height: _____
pregnancy
weight: _____
prenatal diagnostics
desire for child
contraception
complaints
First menstrual period (age):
__________
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Last menstrual period on:
__________
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Number of pregnancies:
_____
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○ regular ○ irregular
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Births (date/sex):
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Miscarriages: ○ strong ○ painful
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Abortion:
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Tube pregnancies:
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Anamnesis
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Dr.med. S. Jahn
Illnesses (lower abdomen, breast, high blood pressure, thyroid gland,
jaundice, vascular problems, drugs, alcohol, heart, kidneys, gallbladder,
sexually transmitted diseases, psychological problems, etc.)
____________________________________________________________
____________________________________________________________
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Do you had any surgery in lower abdomen?
_______________________________
Do you take the contraceptive pill?
Have you used a spiral (IUD)?
○Yes
○Yes
○No
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Since _____ Preparation______
○ No
Since ____
Do you used natural contraception (condoms, temperature method etc.)?
○Yes
!
○ No
Do you take hormone preparations?
○Yes
○No
Since _____
Preparation ______
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Do you take any other medications?
○Yes
○No
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Since _____ Preparation ______
○Yes
○No
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Against________________
Are you known to have allergies?
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Anamnesis
Dr.med. S. Jahn
Do you smoke?
○Yes
○No
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How much ? _____/day
Illnesses in your family:
(lower abdomen, breast, high blood pressure, diabetes, cancer, vascular
illnesses, heart attacks etc.)
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Last gynaecological examination:
__________________________________
__________________________________
__________________________________
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Family practitioner:
__________________________________
__________________________________
__________________________________
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