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The purpose of this questionnaire is to obtain an overview of your state of health and to provide the doctor with information about it. Please bring your vaccination booklet, medical reports or significant medical examination results with you.

All of the enclosed information is subject to medical confidentiality.

    Family history

    Please indicate if any member of your immediate family (parents, grandparents, aunts and uncles, brothers and sisters or children) has suffered or is suffering from any of the following diseases/conditions:










    Personal history







    Habits/Lifestyle














    Medical management:




    Complaints

    Have you recently had:


    Female genitalia