Leading you to better health
YOUR HEALTH PROFILE
Dear Guest A multidisciplinary team of experts looks after your health and well-being at Waldhotel Health & Medical Excellence and setting new standards in preventive medicine. In order to cater to your needs and to prepare for your upcoming stay with us, our medical team will review your state of health, based on the information provided by you, ensuring that all tests, therapies and treatments to be recommended will serve your well-being to your greatest advantage. This will also enable us to reserve potentially necessary important medical appointments for you and to schedule your individual therapy as efficiently as possible. ‘Natural & Discreet’ — we guarantee that all of your data will be treated in compliance with the Swiss medical codes of confidentiality and data protection.
Personal information Last Name / First Name: Street / House Number: Zip Code / City: Country: Telephone / Mobile: E-mail: Date of Birth: Children / Age: Profession: Hobbies:
All of your data is confidential and will be under review by the Medical Team at Waldhotel Health & Medical Excellence lead by Prof. Dr. med. Verena Briner. We kindly request that you return the completed questionnaire to us no later than 14 days before your scheduled arrival. Sending options: Fax: +41 (0)41 612 66 11 E-mail: medical@buergenstock.ch We appreciate your assistance and extend our best wishes for an enjoyable journey, Your Waldhotel Team
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YOUR HEALTH PROFILE 2 / 8
Have you ever been treated in a medical establishment such as Waldhotel Health & Medical Excellence?
No
Yes. If yes, where and for how long, with what results?
Illnesses Have you suffered from any chronic or acute disease for which you are now being treated?
No
Yes. If yes, which ones?
Have you suffered serious illnesses or accidents in the past?
No
Yes. If yes, which and when?
Have you ever undergone surgery?
No
Yes. If so, which type and when?
For Women Yes No Regular cycle: Menopause: Pregnancy:
If yes, which week?
Have you undergone any hormonal pregnancy in the past?
Last gynaecological examination:
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YOUR HEALTH PROFILE 3 / 8
Allergies / Intolerances Have you been diagnosed with any allergies / intolerances? None Antibiotics Gluten Pollen
X-ray contrast agent
Fructose
Animal hair
Local anaesthesia (e.g. dentist)
Lactose
House dust
Cosmetics / Preservatives Flower
Other allergies or intolerances:
Diagnostics Have any of the following examinations been performed within the last 12 months? If so, on which areas of the body and with what results? X-ray: Ultrasound: Gastroscopy: Colonoscopy: Cystoscopy: Bronchoscopy:
Computer tomogram scan, magnetic resonance imaging (CT scan, MRI):
Nuclear medical diagnostics (scintigraphies), e.g. thyroid, pulmonary
embolism:
Other examinations:
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Medication Which medications or additives (e.g. nutritional supplements or vitamin preparations) are you currently taking? Name
Since when? (month, year)
Dosage
Do you take any blood inhibitors, clotting agents or platelets?
No
Yes, please specify:
Nutritional Profile Do you eat regularly?
Yes
No
Are you currently following a special diet? If so, please give details:
When do you eat your main meal?
Morning
Midday
Describe your typical daily diet: Breakfast Lunch Dinner Between-meal snacks Drinking habits
Nicotine, type: Number / day Alcohol, type: Glasses / day Coffee, type: Cups / day
Evening
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YOUR HEALTH PROFILE 5 / 8
Exercise Do you exercise regularly?
Yes
No
If yes, how much time do you spend exercising per week? Which type of exercise / sport?
Your height (cm):
Your weight (kg):
Family medical history Other relatives, relation: Father
Mother
Siblings
Stroke Heart attack Diabetes High blood pressure Adipositas / Obesity Elevated blood fat levels Mental illnesses Alzheimer’s / Dementia Cancer, please specify Other, please specify
Mood / Disposition
Cheerful
Happy
Depressed
Aggressive
Balanced
Lonely
Sad
Exhausted
Which are the two most typical moods for you?
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YOUR HEALTH PROFILE 6 / 8
Sleep Habits On this scale of 1 to 10, please mark the number that corresponds to the quality of your sleep: Very bad Very good 1 2 3 4 5 6 7 8 9 10 Yes No Difficulties falling asleep Difficulties sleeping through the night Snoring Apnoea / Suspension of breathing Night sweats Morning tiredness
Do you suffer from any of the following symptoms? Yes No Lumbago / Back pains Joint pain High blood pressure Heart disease Digestive problems Acid reflux Diarrhoea Kidney disease Flatulence Constipation Shortness of breath Muscle cramps Restless leg syndrome Headaches Skin rashes
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YOUR HEALTH PROFILE 7 / 8
Pain History Do you suffer from frequent pain?
No
Yes. If yes, where:
Can you link the pain to a specific event or activity?
How has your pain been treated up until now?
On this scale of 1 to 10, please mark the number that corresponds to your subjective state of health: I feel very sick
I feel very healthy
1 2 3 4 5 6 7 8 9 10
Personal Health Objectives What are your expectations of your stay at Waldhotel Health & Medical Excellence, e.g. fitness, weight control, exercise, nutrition, improved appearance, stress management etc.?
Additional information that you consider important:
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YOUR HEALTH PROFILE 8 / 8
Therapy requests:
Requested additional specialist consultations / examinations in the following special fields: Urology Gynaecology Dermatology
Psychology / Coaching
Cardiology
Ear nose and throat medicine
Dental medicine
Orthopaedics Other:
Should you require a medical expert or medical examinations including tests or treatments in another hospital or a specialized institution (e.g. colonoscopy, CT scan or MRI, coronary angiography, etc.), then these institutions are liable for the medical consultation, tests and treatments. The institutions and their personnel act independently and not on behalf of the Bürgenstock Hotels AG. Therefore the contractual relationship is between you and the institution and/or medical practitioner not the Bürgenstock Hotels AG. We remain free from any liability.
We thank you for your time and look forward to meeting with you in person to discuss your issues and concerns.
Location, Date Guest Signature
6363 Obbürgen – Switzerland T +41 (0) 41 612 66 00 F +41 (0) 41 612 66 11 medical@buergenstock.ch www.buergenstock-waldhotel.ch