TEstseite ANAHA

    [uacf7_step_start uacf7_step_start-901 "Schritt Eins"]

    Persönliche Daten

    [uacf7-row]
    [uacf7-col col:6] [/uacf7-col]
    [uacf7-col col:6] [/uacf7-col]
    [/uacf7-row]


    [text* geburtsdatum maxlength:10 placeholder "TT" autocomplete:bday]

    [uacf7-row]
    [uacf7-col col:6]
    [text* telefon maxlength:15 pattern="[0-9\+]+" autocomplete:tel]

    [/uacf7-col]
    [uacf7-col col:6] [/uacf7-col]
    [/uacf7-row]

    [uacf7_step_end]

    [uacf7_step_start uacf7_step_start-902 "Schritt Zwei"]

    Sind folgende Krankheiten bei Ihnen bekannt? Wenn ja, seit wann?

    [uacf7-row]
    [uacf7-col col:6]
    Bluthochdruck
    [/uacf7-col]
    [uacf7-col col:6]
    Herzkranzgefäßerkrankung, Herzinfarkt
    [/uacf7-col]
    [/uacf7-row]

    [uacf7-row]
    [uacf7-col col:6]
    Angeborene oder erworbene Herzerkrankungen
    [/uacf7-col]
    [uacf7-col col:6]
    Schlaganfall
    [uacf7-col col:6] seit wann? [select jahr_schlag "2024" "2023" "2022" "2021" "2020" "2019" "2018" "2017" "2016" "2015" "2014" "2013" "2012" "2011" "2010" "2009" "2008" "2007" "2006" "2005" "2004" "2003" "2002" "2001" "2000" "1999" "1998" "1997" "1996" "1995" "1994" "1993" "1992" "1991" "1990" "1989" "1988" "1987" "1986" "1985" "1984" "1983" "1982" "1981" "1980" "1979" "1978" "1977" "1976" "1975" "1974" "1973" "1972" "1971" "1970" "1969" "1968" "1967" "1966" "1965" "1964" "1963" "1962" "1961" "1960" "1959" "1958" "1957" "1956" "1955" "1954" "1953" "1952" "1951" "1950" "1949" "1948" "1947" "1946" "1945" "1944" "1943" "1942" "1941" "1940" "1939" "1938" "1937" "1936" "1935" "1934" "1933" "1932" "1931" "1930" "1929" "1928" "1927" "1926" "1925" "1924" [/uacf7-col]
    [/uacf7-row]

    JaNein

    JaNein

    [uacf7_step_end]

    [uacf7_step_start uacf7_step_start-903 "Schritt Drei"]

    Weitere Angaben


    JaNein

    NormalDurchfallVerstopfung

    Normalnachts öfter als 1-2 Mal

    ZunahmeAbnahme

    [uacf7-col col:6]

    [/uacf7-col]
    [uacf7-col col:6] [/uacf7-col]

    Medikament

    Morgens

    Mittags

    Nachmittags

    Abends

    Zur Nacht

    Ja

    Ja

    Ja

    Ja

    Ja

    [uacf7_step_end]

    [uacf7_step_start uacf7_step_start-904 "Schritt Vier"]

    Bestätigung



    [uacf7_step_end]