PREAMNESIS QUESTIONAIRE

WHY IS IT IMPORTANT FOR YOU TO FILL IN A QUESTIONNAIRE?

It allows us to get an idea of our patients and your health in advance.
With the help of the questionnaire and the video, we can make an initial assessment of whether we can help you.
You save time and money. You don't have to make a fee-based appointment with us.

Salutation

Name

Please enter your first name

Last Name

Please enter your last name

Email

Please enter an email address

How did you become aware of the Millesi Center? Did a doctor refer you?

Yes No

Please select YES or NO.

Please state the name of your referring doctor.

Please fill out the field.

Have you already booked an appointment?

Yes No

How many operations have already been carried out in this regard?

Please choose.

When was the latest of these operations?

Please choose.

Are you in pain?

Yes No

Please select YES or NO.

Have your complaints already been treated? If yes, what treatments have been carried out?

Please fill out.

Are you in pain?

Yes No

Please select YES or NO.

When was the latest of these operations?

in peace

at activities

How severe is the pain? 0

If you are suffering from restricted movement of the shoulder, arm or hand or there is a brachial plexus injury, please upload a video showing what movement is possible in the affected part of the body.

Upload a video here or use the recording function.

Video recording

Instructions

Instructions as PDF

Have you already booked an appointment?

Yes No