Have out-patient examinations (also medical check-ups and medical check-ups due to pre-existing diseases or development disturbances as well) or treatments by doctors, non-medical practitioners or other persons who have treated you been carried out during the last 3 years?

Did in-patient examinations, in-patient treatments or operations take place within the last 5 years?

Has a psychotherapy been recommended or carried out for the last 10 years or is a psychotherapy intended?

During the last 3 years have you had or do you have an examination, have you been or are you in medical treatment or consultation due to sterility or do you have an unfulfilled wish for a child (to be answered by male and female applicants)?

Is an out-patient or in-patient examination, treatment or operation by doctors, nonmedical practitioners or other persons necessary, intended or recommended?

Have you been suffering from any disease, complaint or addiction (such as drugs, alcohol or medicaments), physical or psychological faults which have not been treated for the last 3 years or are you suffering from them at present? Have you been in need of care during the last 3 years?

Do chronic diseases, permanent or recurring complaints/diseases, organic or physical faults (including maxillodental abnormalities), body implants or prostheses (e.g. breast implants or artificial joints) exist?

Have you ever been diagnosed with HIV (e.g. by an AIDS test)?

Do you have a recognized handicap? If so, please join a copy of the recognition certificate mentioning the wording of your handicap or the degree of the handicap (German GbB).

Have you taken during the last 3 years or do you take medicaments regularly – possibly also for prevention?

Do you wear spectacles or contact lenses or have they been recommended or prescribed? (Please state dioptres from +8/–8 dioptres on.)
In case of short-sightedness or long-sightedness possibly the following monthly surcharge is applicable for the respective person: in tariff AE: € 2.50; in tariff BEa.50/BEb.50/BEc.50: € 0.85; in tariff BEa.70/BEb.70/BEc.70: € 1.20; in tariff BEa.80/BEb.80/BEc.80: € 1.35; in tariff BEb.90/BEc.90: € 1.50.

Have you had dental examinations (dental check-ups as well) or treatment during the last 3 years?

Are you in dental treatment at the moment or is treatment because of dental or orthodontic regulation, periodontosis or dentures being carried out or is it necessary, recommended or intended? (If applicable, please join the tentative treatment plan)

Does a gum disease (e.g. periodontosis, periodontitis) or an anomalous position of the teeth or jaw exist?

Only for persons 16 years of age and older:
Are any teeth (except for wisdom teeth or teeth having been extracted as a result of few space) missing which have not been replaced yet?

Do you have dentures (replaced or crowned teeth, included implants, bridges, crowns, partial crowns and prostheses)? (In case of bridges all relevant teeth are to be counted separately, inclusively the anchor or pillar tooth.)