Name

Date of Birth

Filled out by

Date of Information

Reason for Planned Admission

Referring and Treating Practices

Relevant pre-existing conditions

Previous hospital stays

Support needs during admission

Are you currently taking any medication?

Current Medications with Dosage

Are allergies or intolerances known?

Known allergies and intolerances

Other relevant information

What would you like to discuss personally?

Additions or uncertainties Please mark uncertain information. Adapt professionally and regarding data protection by the institution before use. No diagnostics, triage, or medical advice. Not for emergencies.