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Anamnese-/Patientenbogen Arabisch (Syrien)

Familienname/surname/ :_____________________________________________________________________

Vorname/first name / :___________________________________________________________________________

Geburtsdatum/date of birth/ :________________________________________________________________

Staatsangehrigkeit/nationality/ :_________________________________________________________________

Geburtsland und-ort/Country and city of birth/ :______________________________________________

Sprachkenntnisse/spoken languages/ :____________________________________________________

Bei Minderjhrigen/under age persons/ :

Familienname Vater/surname father/ :________________________________________________________

Vorname Vater/first name of father / :___________________________________________________________

Geburtsdatum Vater/date of birth father / :___________________________________________________

Staatsangehrigkeit/nationality / :________________________________________________________________

Geburtsland und ort Vater/country and city of birth father/ :_________________________________

Familienname Mutter/surname mother / :_____________________________________________________

Vorname Mutter/first name mother/ :____________________________________________________________

Geburtsdatum Mutter/date of birth mother/ :__________________________________________________

Staatsangehrigkeit/nationality/ :______________________________________________________________

Geburtsland und ort Mutter/ country and city of birth mother/ :_______________________________

Telefon/phone/ :____________________________________________________________________________

Strae/street/ :_______________________________________________________________________________

PLZ/post code/ :______________ Wohnort/residence / :_____________________________________

Hat oder hatte der Patient/The patient has or has had/ :

Allergien/allergies to (which substances) / :_______________________________________________________

Diabetes/diabetes/ :___________________________________________________________________________

Schilddrsenerkrankung/disease of the thyroid gland/ :______________________________________

Infektionskrankheiten/do you have infectious diseases (hepatitis, HIV, AIDS, tuberculosis.)/

______________________________________________________________________________________:

Blutgerinnungsstrungen/bleeding disorder/ :_________________________________________________

Herz- oder Kreislauferkrankungen/heart disease, circulatory trouble/ :___________________

Nierenerkrankungen/diseases of the kidney or anomalies/ :______________________________________

Asthma/asthma/ :______________________________________________________________________________

Schlaganfall/stroke/ :______________________________________________________________________

Tumor, Krebs/tumors, cancer/ :_____________________________________________________________

Anfallsleiden/epilepsy/ :_____________________________________________________________________

Besteht eine Schwangerschaft/are you pregnant/ :____________________________________

Magen-/Darmerkrankung/gastro-intestinal disease/ :______________________________________

Haben Sie irgendwelche anderen Krankheiten/do you have any other diseases?

:________________________________________________________________________________________________

Nehmen Sie regelmig Medikamente (welche?)/do you take any medicine regularly (which?)

: ,

_________________________________________________________________________________________________

TheissenSchreibmaschinentextMit freundlicher Genehmigung durch den ZBV Niederbayern