Medical History Form

Please fill out this form carefully before your first consultation. Your information will help me prepare for our appointment and provide the best possible care.

Personal Information

First name *

Last name *

Date of birth *

Email *

Phone number

City / Country

Reason for Consultation

What is the reason for your consultation? *

Please describe your symptoms or concerns in detail:

Medical History

Do you have any pre-existing conditions?

Previous surgeries (gynecological and others):

Current medications and supplements:

Known allergies or intolerances:

Gynecological History

Date of last menstrual period:

Average cycle length (days):

Current method of contraception:

Pregnancies and births (number, year, type of delivery):

Lifestyle

How would you describe your diet?

Physical activity (type and frequency):

Stress level and sleep quality:

Additional Information

Lab results, doctor's letters, ultrasound images or other documents (optional)

PDF, JPG or PNG. If upload doesn't work, you can email documents to contact@germangyn.online.

Drag files here or browse

PDF, JPG, PNG — max. 10 MB per file, up to 5 files

Is there anything else you would like to share?

I consent to the processing of my health data in accordance with the Privacy Policy for the purpose of medical consultation. *

Your data will be transmitted in encrypted form and processed exclusively for the purpose of medical consultation. You can find more information in our Privacy Policy.