ANAMNESIS
ANAMNESIS
ANAMNESIS
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<strong>ANAMNESIS</strong><br />
SURNAME: …………………………………………………….<br />
FIRST NAME: …………………………………………………..<br />
TITLE: …….............................................................…......…<br />
PROFESSION: …………………………………………..……..<br />
ADDRESS<br />
street: …………………………………………………………..<br />
zip code: …………...place of residence: ……………….…<br />
BIRTH DATE: ………………………………………………..…<br />
PHONE NUMBER<br />
Private: …………………………………………………………<br />
Office: ………………………………………………………..…<br />
FAX: …………………………………………………………….<br />
E-MAIL: …………………………………………………………<br />
HANDY: …………………………………………………………<br />
INSURANCE<br />
Name of insurance: …………………………………………..<br />
Number of insurance: ………………………………………..<br />
Supplementary insurance: ................................................<br />
1/7
Family diseases:<br />
Hereditary diseases: ..............................................................<br />
Diseases of parents you suffer from......................................<br />
NO family diseases at all<br />
Personal diseases:<br />
Children`s diseases:<br />
mumps German measles<br />
measles others: .................................<br />
chickenpox NO children`s diseases at all<br />
Other diseases:<br />
accidents:...............................................................................<br />
surgery:........................................……...................................<br />
others:.....................................................................…............<br />
NO diseases at all<br />
Current diseases:<br />
diabetes<br />
are you suffering from a heart condition<br />
do you have stomach problems<br />
rheumatism<br />
high blood pressure<br />
nervous disorders<br />
other diseases: ................................………..…....................<br />
NO current diseases at all<br />
Are you allergic to anything?<br />
to:...............................................................…..….................<br />
NO allergical reactions at all<br />
2/7
Which medicine are you using now instead for your eyes?<br />
........................................................................................<br />
........................................................................................<br />
NO medicine at all<br />
Do you suffer from?<br />
Epilepsy<br />
apoplexy<br />
heart attacks<br />
coagulation problems<br />
high blood pressure<br />
high cholesterine, triglicerine<br />
mental disorders<br />
NO problems at all<br />
Are you using medicine like<br />
Sintrom<br />
Marcoumar<br />
Thrombo ASS<br />
Plavix<br />
Heparin (Lovenox, Fragmin,…)<br />
NO medicine at all<br />
Concerning your eyes:<br />
Which EYE-PROBLEMS do you have?<br />
........................................................................................<br />
NO problems at all<br />
Did you have some SURGERY on EYES ?<br />
........................................................................................<br />
NO surgery on eyes at all<br />
3/7
Do you wear SPECTACLES ?<br />
Glasses for distance<br />
Reading glasses<br />
Bifocal, trifocal glasses etc.<br />
NO spectacles at all<br />
Who prescribed your spectacles?<br />
optician<br />
eye specialist<br />
when? ..............…………….......<br />
Do you wear CONTACT LENSES ?<br />
stabile lens<br />
soft lens<br />
NO contact lens<br />
Who prescribed your contact lenses?<br />
optician<br />
eye specialist<br />
Do you have problems with your contact lenses?<br />
..............................................................................................<br />
For how long? ......................................................................<br />
NO problems at all<br />
Who is your FAMILY DOCTOR ?<br />
name: ..................................................................................…..<br />
address: ……………………………………………………………<br />
………………………................................................................…<br />
4/7
Who is your EYE SPECIALIST ?<br />
name: .................................................................................. ..<br />
address: …………………………………………………………..<br />
...................................................................……………………..<br />
Date of LAST CONTROL ? ................................................. ..<br />
Who is your OPTICIAN ? .................................................... …<br />
Did we get the ophthalmological RESULTS of your eye<br />
specialist?<br />
yes<br />
no<br />
Has your EYE-PRESSURE been measured?<br />
yes<br />
no<br />
I do not know<br />
If yes, was it ok?<br />
yes<br />
no<br />
I do not know<br />
Did you have a check of your RETINA ?<br />
yes<br />
no<br />
I do not know.<br />
Do you use EYEDROPS? (which ones)<br />
now: ..........................................................................……....<br />
in the past........................................................................…..<br />
NO eyedrops at all<br />
5/7
What are your expectations of today`s examination?<br />
.................................................................................................................................<br />
.................................................................................................................................<br />
Who recommended you to come to our practice?<br />
my doctor ............................................................................<br />
optician ............................................................................<br />
eye specialist ........................................................................<br />
friend of yours ......................................................................<br />
newspaper/ TV (which one?) ................................................<br />
internet<br />
infoscreen in the subway<br />
informative event, informative postcard<br />
others .................................................................................<br />
Did you visit our HOMEPAGE before contacting us for an<br />
appointment?<br />
yes<br />
no<br />
If you did so, has your decision to fix an appointment be<br />
influenced by the positive valuation of our homepage?<br />
Yes<br />
No<br />
6/7
AGREEMENT OF PAYMENT<br />
The bill for my work and the one of my collagues<br />
corresponds to the valid agreements of the Tyrolean<br />
General Medical Council.<br />
It is possible to submit this bill in order to receive a partial<br />
refund.<br />
I point out that preliminary examinations will be done as<br />
well by my assistants or trained staff in order to avoid long<br />
waiting periods. Even treatments or controlls could be<br />
carried out by my assistants.<br />
All kind of information or further details on phone are not<br />
binding and without guarantee and we do not legally<br />
respond to it at all.<br />
It is possible to pay the bill immediately after the<br />
examination by bancomat, credit card or by cash payment.<br />
Visacard Eurocard/ Mastercard<br />
Credit card number.............................expiry date............……<br />
I agree to all points mentioned above<br />
7/7<br />
Univ.-Prof. Dr. Mathias Zirm<br />
………………………. …….…………………………..<br />
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