GER | ENG

Medical History Questionnaire

step {1} from {2}

Personal Data

Child's family name*

Child's first name

born on

Nationality

Number of other siblings

Native language (Mother/Father)

Number of adults in the household

Has been attending a crèche/ daycare/kindergarten for... (years)

Name and address of legal guardian

Family name

First name

Postcode

Place of residence

Street, house number

Phone

E-Mail*

Consent for consultation with the kindergarten

The social medicine specialists obtain important information about your child's health and development from the responsible educators.
Consent to the exchange of your personal data with the kindergarten is voluntary. It will only be deemed to have been given if you check the relevant box. Without your express consent, consent is deemed to have been refused.

I agree to the exchange of information with the kindergarten.

Name of institution

Is there anything else you would like to tell us?

Medical History Questionnaire

Medical History Questionaire

for school entry health examination

Medical History Questionaire

for school entry health examination

Medical History Questionaire

for school entry health examination

Medical History Questionaire

for school entry health examination