Naturopathic Practice Egon Philipp
Wettersteinstr. 4 · 82024 Taufkirchen, Germany
Phone +49 174 317 5120 · info@naturheilpraxis-philipp.de

For new patients

Medical history form

Request an appointment and complete the medical history form in one step: fill in this form in advance — including your preferred dates. At the end, send everything to the practice via WhatsApp or email and attach your medical records right there. This way I already know your concern before your first conversation. Nothing is stored or transmitted automatically.

Personal details

Last name, first name Date of birth Phone Email

Preferred appointment

Preferred date 1 Preferred date 2

Your concern What brings you to me? What symptoms do you have, and since when?

Known diagnoses

High blood pressure Diabetes Thyroid condition Cardiovascular disease Asthma / respiratory Gastrointestinal complaints Rheumatism / joints Migraine / headaches

Health history Other pre-existing conditions Operations and accidents (with year) Allergies and intolerances Current medication (including over-the-counter and supplements) Known conditions in your family

Lifestyle

Smoking Alcohol Exercise / sport Sleep

Anything else Is there anything else I should know? (e.g. pregnancy, ongoing treatments, wishes)

Your summary

Send via WhatsApp Send via email

Attach your records right away: After clicking, WhatsApp or your email program opens with the completed medical history form. Simply attach your current records there before sending — e.g. lab results, doctor's letters, X-ray or MRI images (as photo or PDF). That way everything is at the practice before your first appointment.

Nothing is sent until you yourself click "send" in WhatsApp or your email program. Note: email and messengers are usually not fully encrypted. If you prefer not to send health data this way, simply print the summary and bring it along with your records to your appointment.

Privacy: This form is completed entirely in your browser. No details are stored or transmitted automatically — your data only leaves your device if you yourself click "Send to the practice" and send the email.

Naturopathic Practice Egon Philipp · Wettersteinstr. 4 · 82024 Taufkirchen, Germany · +49 174 317 5120 · www.naturheilpraxis-philipp.de
This medical history form is completed in advance and does not replace diagnosis or treatment by a doctor or Heilpraktiker.