Personal information »hormones man«

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 operation in the past?*

Do you suffer from a serious illness?*

Have any members of your immediate family (parents, siblings) been diagnosed with vascular diseases (heart attack, stroke, thrombosis, dementia, arterial occlusive disease)?*

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?*
Extreme sensitivity to cold?*
Loss of libido?*
Loss of energy / listlessness?*

Which of these symptoms would you identify as the main issue?

General information




How did you hear about us?

Do you already have an appointment with 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.


Was ist die Summe aus 3 und 8?
SSL

All forms within our website use a secured connection through SSL encryption (Secure Socket Layer protocol). Your data is also sent to us via secure connection. Your data is protected during transmission by the SSL protocol and 256-bit key and cannot be viewed by third parties. The connection secured with SSL encryption can be recognized by the extension https:// in the address bar.