Krankengeschichte Patientinnen Frauenarztpraxis

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Dr. med. Margarita Kiewski & Dr. med. Wolfgang Hirsch
Tel: 261 2043 www.praxis-hirsch-kiewski.de
e-mail adress: ____________________ @
o name: o Are you on medication? pills/tablets? □ Yes □ No
Which?
o height: cm urination normal? □ Yes □ No
o weight: kg stool normal? □ Yes □ No
o What is your profession / work?
o What is the reason for your visit? Do you have any allergies?
□ pain □ normal check up □ smear □ pregnancy Which?
o When was your last visit to a gynaecologist? o How do you prevent ? □ condom □ nothing
o When was your last cancer prevention check? □ coil(Which? How long have you had your coil?)
□ pill (name of the pill)
o How old were you when you got the first period? ____ years
o When was your last bleeding?/period? (1st day)
o Cycle interval (days): ____ days o Have you had rubellos / measles or chicken pox? □ Yes □ No
o Is your period □ weak? □ Normal? □ Strong?
o Is your bleeding painful? □ Yes □ No o Do you smoke? □ Yes □ No How many cigarettes per day? ____
o Age when menopause began? ____ years o Are you interested in following main point?
o Do you have children? □ Yes □ No
o When was the child born (□ boy □ girl?) o year: □ extensive prevention
o Have you had miscarriges? □ Yes □ No □ infectionstest
o Have you had abortions? □ Yes □ No □ smear/blood-test
o Have you had any operations? □ Yes □ No □ vaccination
o Have you had gynecological operations? When? □ traditional Chinese medicine
□ child wish
o Do you have the following: □ high blood pressure □ intimate surgery
□ blood clot □ prevention advice
□ circulation / problems with your heart
□ headache
o Illnes s in your family: □ diabetes For further questions please do not hesitate to contact us!
□ thrombosis
□ high blood pressure Tel: 030 261 2043 info@praxis-hirsch-kiewski.de
□ cancer