Medical History Form

Please complete this form as fully as possible. Your answers help us understand your health profile and prepare your care individually.

Personal Information

Name *

Date of birth *

Weight (kg) *

Height (cm) *

Occupation *

Contact / Email *

Current Concerns & Goals

Do you currently have any health concerns? If yes, which ones?

What are your goals? (e.g. more energy, prevention, muscle building, performance)

Previous Conditions & Operations

Have you been diagnosed with relevant conditions (e.g. heart, metabolism, autoimmune)?

Have you had any operations?

Family History

Have any of the following occurred in your family (parents/grandparents):

Heart attack / stroke

Cancer (type?)

Dementia / Alzheimer’s

Diabetes / metabolic disorders

Medication & Supplements

Do you regularly take medication? If yes, which?

Do you take supplements? If yes, which?

Lifestyle

Exercise: how often do you train per week?

Sleep

goodmoderatepoor

Diet

mixed dietvegetarianveganlow carbMediterranean

Smoking

noyes, how much:

Alcohol

nooccasionallyregularly

Stress level

lowmediumhigh

Sex-Specific Information

Sex

FemaleMaleDiverse

Signature

Please confirm with your signature that the information provided is true.

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Location

Torstraße 125
10119, Berlin

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New: Card Payment Available

We now accept card payments (EC/credit card) and mobile payments for private treatments. Read the full article on digital payments

Contact

Tel: +49 30 40054273

Fax: 030 / 40054275

Email: info@praxisjona.de

Consultation Hours

Monday

08:30 - 12:30
15:00 - 18:00

Tuesday

08:30 - 14:30

Wednesday

08:30 - 12:30

Thursday

12:00 - 17:00

Friday

08:30 - 12:30

Saturday

Closed

Sunday

Closed

Practice

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Language:DE|EN

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