This document appears to be a patient intake form for a gynecology practice. It collects information about a patient's medical history including current medications, last checkups, menstrual history, pregnancy history, smoking status, family medical history, and reasons for the current visit. The form also asks what preventative services or additional information the patient may be interested in.

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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