Confidential, personal information before the first Therapy-Appointment


Family status
Children (Number of)

I am

How did you find out about us?


The reasons, why you have come to us, are:

Do you have pain?  

Where do you feel the symptoms? (Please hold the left mouse button to draw.)
Reset drawing and start again


Did you previously have the same symptoms?
Are you or have you because of this been on sick leave?
Is it registered as a workrelated condition?
Are your symptoms related to your work?

Have you seen other therapists regarding these symptoms?

Do you or have you had any of the following diseases?:

Do you suffer from the damages caused by a:

Do you take any medicine?

Do you suffer from:...

For ladies only

As a child did you suffer from any of the following diseases?


Riskinformation / Risk disclosure ∇

The duty of care and education requires us to inform every patient about possible risks.

Treatment risks:

Performed by a qualified chiropractor, chiropractic offers a relatively low-risk treatment option for diseases of biomechanical origin.
There are no known risks associated with chiropractic correct treatment of joints in the arms and legs. The chiropractic treatment of the lumbar and thoracic spine is also very low risk. Only in 1:100,000 cases could occur a nerve damage.
Studies show that the risk of injury/damage to the cervical vertebral artery (Ateria vertebralis) is even lower when the cervical spine is chiropractically adjusted. A stroke can only occur in 0.64 out of 1,000,000 cases. However, it should be noted that in patients with pre-damaged blood vessels (risk factors: smoking, overweight, diabetes etc.) normal everyday behaviour, such as looking over the shoulder while driving a car, could also lead to such a complication.

Treatment reactions:

After the treatment, pain like delayed onset of muscle soreness might occur sometimes within the first 48 hours. Usually these disappear quickly when the affected areas are cooled. Temporary tiredness and/or headaches may also occur. A certain feeling of instability may also occur in the treated area for some time. If you need further information, please contact your treating chiropractor.

Data Protection ∇

(In relation with the treatment form. You can find the complete and current data protection on our website at Data-Protection)

We collect, process and use your data only within the scope of the legal provisions. This data protection declaration applies exclusively to the use of the websites we have indicated. It does not apply to the websites of other service providers to which we merely refer by a link.

The protection of your privacy is very important to us. Therefore, please be assured that the personal data provided by you on our websites will only be processed or used by us to process your enquiries or to use the services offered on the websites and not for any other purposes.

We hereby assure you that we will not pass on your data to third parties without your express consent, unless we are legally obliged to do so. We will treat the data you provide us with as strictly confidential. We are committed to professional discretion.

Personal data is only collected if you provide us with it voluntarily, for example in the course of a contact request and/or in the context of the initiation or conclusion of a treatment contract. We collect, process and use your data only within the scope of the treatment contract with you in compliance with the statutory provisions.

However, we would like to point out that it is always possible that third parties may take note or falsify your data when transmitting data via the Internet. If you request us to do so, we will grant you access to the data we have stored about you or delete it. If you wish to correct, delete or view this data, all you have to do is write to the address given in the imprint.

Knowledge and conscience Headline

Click here to print the formular