Personal information for men

In order to prepare for your visit, we would appreciate it if you could provide some answers to the following questions. Alternatively, you can download a PDF here to print and fill in with your personal information.

The form will be treated confidentially and only used for the purposes of your treatment. None of the data provided will be transferred to third parties!

Our questions for you

All questions marked with * are required fields.



Do you have any allergies?*

Do you take medication?*

Have you had an important operation in the past?*

Do you suffer from a serious illness?*

Do any of your parents, grandparents or siblings have vascular diseases (heart attack, stroke, thrombosis, dementia)?*

Do you smoke?*

Do you suffer from any of the following symptoms:

Depression?*

Memory loss?*

Weight gain or loss?*

Hair loss?*

Hot flashes?*

Difficulty sleeping?*

Loss of libido?*

Loss of energy / listlessness?*

Your MAIN ISSUE?*

General information




How did you hear about us?

Data protection notice

We would like to alert you to the fact that all data transmitted to us is stored and processed with the help of electronic data processing. The data entered in this form will be deleted after submission. We handle the information you provide with strict confidentiality and do not transfer it to any other party. Please consult our data protection notice.


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