Gesundheitsamt - Ärztlicher Dienst Konrad-Adenauer-Str. 1 91413 Neustadt a.d.Aisch
Medical History Questionnaire
Your child will start school this year. You have received a written invitation from us to schedule an appointment for the school entry medical examination.
As part of this examination, your child's medical history will be recorded. Completing the form is voluntary and helps in better preparing for each individual case, as well as in collecting anonymous data for the "Bayerische Landesamt für Gesundheit und Lebensmittelsicherheit".
Estimated time to complete: 10 minutes.
I would like to read further data protection information.
Information on data collection and processing
With this consent, you agree to your personal data being collected and processed electronically. The data will be collected and stored exclusively for the purpose of the transaction/processing activity you have selected from the online services offered by the Neustadt a.d.Aisch-Bad Windsheim District Office.
Your consent will be logged. The data will not be passed on to or processed by third parties.
Data protection regulations
As a public body, the Neustadt a.d.Aisch-Bad Windsheim District Office is subject to the provisions of the General Data Protection Regulation (GDPR) and the Data Protection Act for the State of Bavaria (DSG Bayern). The protection of your personal data is very important to us. Your data is therefore protected in accordance with the statutory provisions and all requirements of the GDPR and the Data Protection Act for the State of Bavaria are complied with.
Detailed data protection information on the processing activities can be found in the appendix to the data protection declaration on the LRA Neustadt a.d.Aisch-Bad Windsheim website.
Right to information and contact addresses
If you would like information about your personal data or its correction or deletion, or if you have further questions about the use of your personal data provided to us, please contact the official data protection officer.
Contact datenschutz@kreis-nea.de
I have read the data protection information and hereby give my consent to the collection and processing of data.*
Before confirming the checkbox, please read the data protection information according to Art. 13 GDPR of the respective department.
Only with the consent to data collection is the form processing released!
The citizen account (BayernID) is the central access point to online administrative services for private individuals. If you register once, you can use the citizen account for the online services of all authorities.
The form is automatically pre-filled with the data from the citizen account.
You can find further information about Bayern ID here
If you don't have a citizen account, you can still send us all the necessary data for verification.
Childs family name
Childs first name
Born on
Nationality
Street, house number
Postcode
Place of residence
Number of other siblings
Number of adults in the household
Native language (mother)
Native language (father)
Child lives in germany < 1 year
Vorgangsdatum
créche/daycare/kindergarten before school
Attending a créche/daycare/kindergarten in years
créche/daycare/kindergarten (type)
créche/daycare/kindergarten (name)
Family status
Salutation
Family name
First name
Phone
With this selection I agree to receive unencrypted e-mails in case of appointment information from the public health department. This consent can be revoked at any time without giving reasons. The reply by e-mail remains lawful until revoked.
Pregnancy and birth
Information in yellow booklet
Completed pregnancy weeks
Birth weight (grs.)
Multiple birth
Development
Has any delayed development ever been determined in your child?
First words (such as mum, dad, car) by 18 months
Unassisted walking by 18 months
Speech disorder during development
Which speech disorders?
Child grows up multilingual
Further languages
In contact with the German language
From which age?
years
month
Is your child
Does your child have or has your child had one of the following illnesses or health impairments?
Visual impairment
Strabismus treatment
Glasses
Does your child suffer from severe hearing impairment?
Elterneinwilligung Hören
Severe congenital hearing impairment
Acquired chronic hearing impairment
Wears hearing aid since
left ear (month)
left ear (year)
right ear (month)
right ear (year)
Wears cochlear implant since
Rare congenital metabolic or hormone disorders
MCAD-Mangel
Hypothyreose
PKU
AGS
Mukoviszidose
Other chronic illnesses?
Which chronic illnesses?
Severe handicap
Which severe handicap?
Must take the following medication regularly
Which medication?
Are you aware of illnesses your child may have that require specific procedures in emergency situations (e.g., allergies, epilepsy, etc.)?
Which illnesses?
Has your child ever had any of the following assistance measures or treatments?
Participation in German prep classes
Start (month/year)
Speech therapy (logopedics)
Since when (month/year)
Remedial education/orthopaedagogy/ergotherapy
Physiotherapy
Family doctor/pediatrician
Status
Kennung
Ergebnis
All the provided data has been reviewed again and is correct.*
Here you can download the completed form for your records.