Questionnaire First NameLast NameDate of birth DD/MM/YYTelephone Number/sEmailFull AddressOccupation/s (or last occupation) Name and address of your GPTelephone NumberHow did you find out about us Are you pregnant? Yes NoWhat are your main complaints? (in order of priority)2nd3rdWhich other therapists have you already seen regarding these complaints. (Please give also their addresses and telephone number if not included earlier)Family Doctor Which treatment has given you most relief ? Other Doctors / therapists Which treatment was not helpful? When and why have you received treatment in hospital / in a health clinic? ReasonWhenAre you taking medication? Yes NoWhat Medictaion do you take regularlyWhat medication do you take occcasionallyPreviousNextHave you had the following diseases, or have you been vaccinated?I had this diseaseI have not had this diseaseDon't KnowVaccinatedMeaslesMumpsRubellaMMRWhooping CoughSmallpoxScarlet FeverHepatitis A/B/CYellow FeverDiphtheriaCovid-19Other vaccinations, when?Which illnesses have occurred (several times) in your family? (Please give illness and family member)Illness 1Illness 2Illness 3Family memberFamily memberFamily memberWhich operations have you undergone? Only fill in those that apply, with year of opperation - Leave Blank if it does not applyTonsilsGall BladderKidneysSinusesAppendixEarsStomachOther Operations for example lower abdomen, hernias, jaw surgery, extraction of wisdom tooth, organ transplant - Please specifyAccidents / fractures Severe illnesses / infections Addictions Medication Drugs Alcohol NicotineOthers not listed aboveSkin diseases, hair loss, skin fungus, fungus of the genitals:Overseas stays eg. India, Africa, South America Treatments for fungus, parasites, intestinal reconditioning:Pregnancies, births, miscarriages, abortions, intake of the pill, coil PreviousNextAllergies / intolerances? - Give name and when startedDental procedures (root canal treatment, tooth extractions, amalgam removal, implants etc.) Neurological illnesses (problems with brain or nervous system, multiple sclerosis, ME, psychiatric diseases) Give Date it startedAutonomic nervous system disorders: (1 = never, 10 = a lot)12345678910Increased temperatureSweatingNight sweatNervousnessEasily fatiguedConcentration problemsWeakness of memoryDizzinessWeather sensitivityHeadachesHeadaches - Where: one sided/ on both sides, when, how often?Cardiovascular System (1 = never, 10 = a lot)12345678910High blood pressureLow blood pressureVein inflammationsVaricose veinsHeart valve defect Myocardial diseaseHeart attack(s)ArrhythmiaPain in the heart regionPoor circulationPoor circulation - Where aboutsPreviousNextHormonal disordersThyroidParathyroidPancreasOvariesTesticlesPituitaryDiabetesDiseases of the respiratory tract / lungsBronchitisPneumoniaSinusitisInflammation of throat / mouthLife StyleCheckbox GridNeverRarelyOccasionallyRegularlyA lotThis is my problemSmokingAlcoholDrugsSportsWhich Sports?Inner and outer environmentCheckbox GridAlwaysFrequentlyOccasionallyRarelyDo your suffer from stress, fears and / or worriesDo you feel emotionally stressedAre you able to relaxDo you experience emotional crisisDo you have problems with your partnerAre you satisfied with yourself and the people around youDo / did you work with solvents, cleaning agents,disinfectants, colours, varnishesAre / were you exposed to exhaust fumes: cars / traffic / industryDo other people smoke while they are around youDo you use a mobile or codless phoneAre you exposed to electrosmogDietary habits(1 = never, 10 =a lot)Checkbox Grid12345678910Sugar, sweets,bkery productsMeat, milk / milk productsSalad / vegetablesFruitWhole grain productsLemonade / coke / fruit juicesCoffeeTeaI drink ….. litres of water every day: up to 1 litreup to 1.5 litresup to 2 litresIup to 2.5 litresmore than 2.5 litresAre there things in your life which you would like to change but are not able to in your private life / work life etcSleep disorders eg. can’t fall asleep, can’t maintain sleep, waking up ahead of timeDo you have painful diseases of the joints / muscle / soft tissues? PreviousNextAppetite Constipation windStools regular irregular shaped pulpy smellyProblems with... liver gall bladder haemorrhoids othersGynaecological / urological diseasesMenstruation disordersLengthy menstruation Sterility, unfulfilled child wish Painful menstruationStrong bleeding during menstruationPain in breastsKidneysprostateKidney or bladder stonesBladderInflammatory diseasesPsychosocial environmentDo you feel stressed by people who are around you. eg family members, neighbours, work colleagues etc. Do you wish to inform us of any other relevant informationDate Previous Submit Form
