Questionnaire human

IDENTIFICATION NUMBER:

FIRST AND LAST NAME:

STREET ADDRESS:

ZIP CODY & TOWN/CITY:

COUNTRY:

EMAIL ADDRESS:

PHONE NUMBER:

YEAR OF BIRTH:

HEIGHT IN CM:

WEIGHT IN KG:

SEX:

FEMALEMALEN/A

RECIPIENT OF THE RESULTS:

TO MY ABOVE-MENTIONED EMAIL ADDRESSTO MY ALTERNATIVE PRACTITIONER, PHYSICIAN, THERAPIST, ETC.

RECIPIENT OF THE RESULTS:

Please remark only what applies

0. None 1. Rarely 2. Moderately 3. Regularly

-- FROM HERE ON, ALL INFORMATION IS VOLUNTARY --

PREGNANT:

YESNO

Please mark complaints by severity only

0. None 1. Slight/Rarely 2. Moderate/Moderately 3. Strong/Regularly

HEALTH PROBLEMS/DISEASES

	0	1	2	3
Addictions
Aggression
Allergies
Arthritis
Arthrosis
Asthma
Candida
Cardiac/circulatory problems
Cholesterol problems
Constipation
Depression
Diabetes
Diarrhea
Eating disorders
Eczema, herpes
Exhaustion
Eye disease
Hair problems
Hearing problems
Hormonal problems
Hyperactivity
Hypertension
Infections
Inflammation
Intolerances
Joint diseases
Lack of drive
Memory disorders
Menstrual disorders
Mental illness
Metabolic diseases
Olfactory sense problems
Osteoporosis
Parkinson’s disease
Physical weakness
Poor adrenal gland function
Poor liver function
Prostate disease
Rheumatoid muscular complaints
Skin rashes
Sleep disorders
Stomach problems
Stress
Tasting problems
Teeth
Thyroid problems
Tinnitus
Intolerance
Constipation
Wound healing disorder
Teeth

Please list any other diseases, information, or supplements and medications that are being taken.

OTHER:other complaints or remarks

SUPPLEMENTS THAT ARE BEING TAKEN:(e.g. food supplements that are currently being taken)

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	YES	NO
Mao inhibitor
Painkillers
Cortisone
Cardiovascular medication
Neuroleptics
Antibiotics
Hormones/contraceptive pill
Antidepressants