Questionnaire human


Take your time to answer the online questionnaire carefully and make sure that all the details are correct. We will then send you a copy of your completed questionnaire by email.
If you have any questions while completing the questionnaire, you are welcome to call us: 0049 (0) 8382 27924 50.
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1 IDENT-NR.
2 FRAGEBOGEN
SEX:
RECIPIENT OF THE RESULTS:

Please remark only what applies

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

-- FROM HERE ON, ALL INFORMATION IS VOLUNTARY --
LIFESTYLE
0123
Smoking
Endurance sports
Professional sport
Weight training
Vegan
Vegetarian
PREGNANT:

Please mark complaints by severity only


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

HEALTH PROBLEMS/DISEASES
0123
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
MEDICATION:
YESNO
Mao inhibitor
Painkillers
Cortisone
Cardiovascular medication
Neuroleptics
Antibiotics
Hormones/contraceptive pill
Antidepressants

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

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