Physio Anmeldeformular

Application Form

* This information is mandatory.

Gender*: Male Female

Date of birth*

Supplementary Health Insurance*: Yes No

Invoice per Email?

As of January 1st, 2022, all service providers in the healthcare sector are legally obliged to send their patients a copy of the invoice.

Franchise*: 300 500 1000 1500 2000 2500

Underaged Child?

Preferred Contact Method:* Landline Mobile Email Other

In the event of an accident, please fill out the following fields as well

Accident Date

How did you hear about us?*

Family Doctor Recommendation (friends/acquaintances) Internet Other:

Were reviews on the internet (e.g. Google reviews) important to you?*

Yes No

DECLARATION OF CONSENT

My physiotherapist is authorised by me:

• to exchange medical data in connection with my treatment with the referring and treating physicians as well as medical officers of the funding agencies. • to forward the necessary personal treatment data to the billing institution and to the institution responsible for any debt collection, as well as to the appointed lawyer and to the competent state authorities in the event of non-payment of the treatment bill. • to create non-public lists of defaulters, which he/she may exchange with other physiotherapists.

I will be billed privately (without entitlement to reimbursement by health insurance companies) for any agreed treatment appointments which I do not attend and which have not been cancelled at least 24 hours before the appointment. All treatment costs that are not paid by my insurance/ health insurance company will be borne entirely by myself.

Swiss law is applicable.

EXTENDED QUESTIONNAIRE

In order to examine you thoroughly and specifically, we need some information from you. If a question is unclear, simply leave it out. All information is voluntary. We will look at them together later. If you do not wish to fill out this additional form, please click here to go to the "Submit" button. Thank you!

Have you ever been diagnosed with any of the following conditions? Please select.

Covid19 Long Covid19

Cancer: Yes No

Heart condition High blood pressure Circulatory problems Thromboses Asthma Stomach ulcers

Kidney disease: Yes No

Hepatitis Thyroid problems Diabetes Multiple sclerosis Stroke Rheumatoid arthritis

Addiction to alcohol, medications, or other substances

Other inflammatory joint disease: Yes No

Osteoporosis Depression Dizziness Seizure disorder, epilepsy Urinary urgency Tuberculosis

Other

Have you felt down, hopeless, or depressed in the past month?

Yes No

Have you not been interested in or found pleasure in anything in the past month?

Yes No

Have you ever been threatened hurt or intimidated by your partner or someone close to you?

Yes No

Allergies

Are you allergic to any medications? Yes No
Are you sensitive to latex? Yes No

Other allergies that may be important to the treatment?

Are you receiving treatment from any of the following professionals?

Family doctor Psychiatrist/Psychologist Osteopath Physiotherapist Dentist Chiropractor

Other:

Last examination date:

Do you go to age-appropriate preventive checkups? Yes No

In the last three months, have you been treated for any of the above occupational conditions?

Yes No

Please list all surgeries performed on you and each hospitalization with both the reason and approximate date:

Please list any serious injuries for which you required treatment (e.g. broken bones, ligament injuries) and the approximate date of the injury:

Have any of your family members (parents, siblings) ever been treated for any of the following conditions? Please select.

Diabetes Cancer Heart disease High blood pressure Depression Stroke Kidney disease Inflammatory joint diseases

Addiction to alcohol, medications, or other substances

Which of the following medications have you taken in the past week?

Aspirin Vitamines, Minerals Paracetamol Herbal remedies

Ibuprofen, Diclofenac etc.

Medicines for stomach ulcers

Please list the medications you are currently taking as prescribed by your doctor (tablets, injections, medication patches, etc.):

Drinks and Tobacco

How much coffee or other caffeinated beverages do you consume per day?

How many cigarettes do you smoke per day?

For how many years?

No smoking since?

How many days per week do you drink alcohol?

How many glasses of beer, wine or similar do you drink on these days?

Please select current complaints that are new, unusual or atypical:

Weight change Swelling of joints, muscles Nausea, vomiting Fatigue Heavy bleeding Feeling weak Shortness of breath Back pain Frequent urge to urinate Skin alterations Fever, chills, sweating (Possible) pregnancy Stress at work or at home Climacteric, menopause Disorders in sexual function Urinating problems Limbs swelling Tremble Regular cough Diplopia (Double Vision) Swallowing difficulties Loss of visual acuity Heartburn (Acid reflux) Red eyes Constipation, diarrhea Skin rash Blood in the stool Sweating at night Blood in the urine Hearing impairment Changes in bowel habits Unexplained hematomas - bruising

Are there any additional information that might be relevant to your medical evaluation?

I have read the declaration of consent and agree to it.