Registration Form for Health Check-Up
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1 Centramed Baarerstrasse Zug Phone Fax ZSR-Nr. U EAN MwSt. CH Registration Form for Health Check-Up Date: Location: First Name: Last Name: Gender: Street: House Number: City/Zip: Date of Birth: Phone Personal/Business/Mobile: Address: Occupation: Health Insurance: Employer: Which Check-Up would you like to apply for? Basic Check CHF 900 Advanced Check CHF 1'500 Why do you want this Check-Up? Is there a specific reason? Declaration of Consent: I consent to the examination and that storage of the health data collected in the process. The saved data may be used exclusively for scientific purposes. It is to be changed in a way that no connection between the data and my person can be made. My personal data is to be made inaccessible to all users except for Centramed employees. Date and Location Signature Participant
2 Centramed 2/5 Family/Relatives 1. Is anyone in your family suffering or has suffered from any of the illnesses stated below? Heart Attack Stroke Diabetes Mental Illness Pulmonary Diseases Cancer Overweight High Blood Pressure Risk Assessment Heart/Circulation 1. Have you undergone a medical examination (physical examination including a blood pressure reading) in the past 2 years? 2. Have you had an electrocardiogram (ECG) done in the past 2 years? 3. Have your parents/doctors ever spoken to you about cardiac murmurs/anomalies? 4. Have any of your family members, parents, siblings or grandparents, suffered from a heart attack, stroke or cerebral haemorrhage before the age of 60? 5. Did anyone die before reaching 50 years of age? 6. Do any of the following results/illnesses apply to you? Overweight High Blood Pressure Diabetes High Cholesterol Lack of Exercise 7. Do you experience coughing, shortness of breath, closeness or stinging/pressure in the chest or abdominal region while resting or during physical exertion?
3 Centramed 3/5 Personal 1. Do you suffer or have you suffered from afflictions, sicknesses, treatments, operations? If so, please specify. Heart/Blood Pressure Lungs bronchial asthma Stomach/Bowels Liver (jaundice) Kidney/Bladder Skin Eyes Teeth Throat/Pharynx Ears Forehead/Sinus Nervous System Epilepsy Diabetes Allergies Drug Incompatability Mental Illness 2. Have you been vaccinated in the past 5 years (vaccination card)? 3. Have you been hospitalized in the past 2 years? If so, what for? 4. Have you ever received medical treatment for an extended period of time? 5. Have you suffered any injuries, afflictions or operations of the joints, tendons or muscles? If so, please specify. Neck Shoulder Upper Arm Elbow Forearm Wrist Hand Back of the Hand Pelvis Hip Thigh Knee Calf Ankle Foot Achilles tendon Groin 6. Do you take any medication on a regular basis? 7. When was your last dental inspection?
4 Centramed 4/5 8. Do you smoke? n-smoker Occasional Smoker Approximately 1 pack a day More than 1 pack a day Exercise 1. Do you exercise regularly (5 times a week, 30 minutes, medium intensity)? 2. Do you train regularly? If so, what does your training entail? 3. Are you happy with your personal fitness? I would like to do more. It s adequate. I consider myself very fit. 4. Are you training towards a specific goal? If so, what does your training look like? 5. How has your performance developed over the past 2 years? increased constant decreased alternating
5 Centramed 5/5 Interest 1. Have you ever done a Check-Up or Coaching? Athletic (lactate, etc.) Medical Check-Up (GP) Health Check (Nutrition, Exercise, Medical, Life Balance) Nutrition Counseling Fitness Coaching Stress/Burnout 2. How did you find out about our Health Check-Up? Through my employer. Through my health insurance. Over the internet. Through friends/acquaintances. 3. Which of the topics mentioned below are of interest to you at the moment? Exercise Nutrition Fitness Relaxation Stress/Burnout Personal Coaching Life Balance Thank you for your attention! Please send us the completed registration form via info.zug@centramed.ch We will contact you as soon as possible to arrange an appointment.
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