Anamnese-/Patientenbogen Arabisch (Syrien) Familienname/surname/ عائلةاسم ال:_____________________________________________________________________ Vorname/first name / سما:___________________________________________________________________________ Geburtsdatum/date of birth/ دةريخ الوتا:________________________________________________________________ Staatsangehörigkeit/nationality/ الجنسية:_________________________________________________________________ Geburtsland und-ort/Country and city of birth/ دةد الو مكان وبل:______________________________________________ Sprachkenntnisse/spoken languages/ تكلمهاي تلتت اللغا ال:____________________________________________________ Bei Minderjährigen/under age persons/ رّ القص: Familienname Vater/surname father/ بئلة اسم عاا:________________________________________________________ Vorname Vater/first name of father / ب اسم ا:___________________________________________________________ Geburtsdatum Vater/date of birth father / بدة اتاريخ و:___________________________________________________ Staatsangehörigkeit/nationality / الجنسية:________________________________________________________________ Geburtsland und –ort Vater/country and city of birth father/ بدة ا مكان وبلد و:_________________________________ Familienname Mutter/surname mother / مئلة اسم عا ا:_____________________________________________________ Vorname Mutter/first name mother/ م اسم ا:____________________________________________________________ Geburtsdatum Mutter/date of birth mother/ مريخ ولدة ا تا:__________________________________________________ Staatsangehörigkeit/nationality/ م جنسية ا:______________________________________________________________ Geburtsland und –ort Mutter/ country and city of birth mother/ مدة ا مكان وبلد و:_______________________________ Telefon/phone/ لهاتف رقم ا:____________________________________________________________________________ Straße/street/ لشارع ا:_______________________________________________________________________________ PLZ/post code/ بلد رقم ال:______________ Wohnort/residence / السكن مكان:_____________________________________ Hat oder hatte der Patient/The patient has or has had/ ن لد المريضو هل كا لد ا: Allergien/allergies to (which substances) / اسيات حس:_______________________________________________________ Diabetes/diabetes/ سكري:___________________________________________________________________________ Schilddrüsenerkrankung/disease of the thyroid gland/ الدرقية امراض الغدة:______________________________________ Infektionskrankheiten/do you have infectious diseases (hepatitis, HIV, AIDS, tuberculosis….)/ امراض معدية:______________________________________________________________________________________ Blutgerinnungsstörungen/bleeding disorder/ بات نزفية اضرا:_________________________________________________ Herz- oder Kreislauferkrankungen/heart disease, circulatory trouble/ ة الدمويةوعيقلب و ا امراض ال:___________________ Nierenerkrankungen/diseases of the kidney or anomalies/ كلوية امراض ال:______________________________________ Asthma/asthma/ الربو:______________________________________________________________________________ Schlaganfall/stroke/ طة لدماغيةجل ال:______________________________________________________________________ Tumor, Krebs/tumors, cancer/ م سرطانية اورا:_____________________________________________________________