Personal information
Mandatory field Name*
Mandatory field First name*
Mandatory field ZIP Code*
Mandatory field City*
Mandatory field Phone*
Mobile
Mandatory field E-Mail*
Mandatory field Birthday*
Mandatory field DOB*
single
partnership
married
divorced
widowed
Children
Age (Child 1)
Age (Child 2)
Age (Child 3)
Age (Child 4)
Mandatory field Profession*
Diseases
Please indicate if you have had any of the following illnesses:
Thyroid disorders (stroma, over- or underactive thyroid)
Heart diseases (heart attack, heart defect, heart rhythm disturb.)
Gastrointestinal diseases
Kidney diseases
Blood coagulation (blood clotting disorders)
High uric acid/Gout
Joint diseases/Rheumatism
Skin diseases
Ear diseases (hearing aid, tinnitus)
Eye diseases (weak-sightedness, glaucoma)
Liver diseases
Lung diseases (asthma, chronic bronchitis)
Psychological disorder/epilepsy
Circulation- and vascular diseases
Acute or chronic infectious diseases (HIV, hepatitis)
Which main diseases or accidents you have had earlier?
Have you undergone surgery? If yes, which?
Do you have any allergies or intolerances?
Do you have any allergies or intolerances?
Antibiotics
Food
Pollen
X-ray contrast agent
Fructose
Animal hair
Local anesthetics (at the Dentist)
Lactose
House dust
Cosmetics/preservatives
Vitamin B
Other
Diagnostik
Which body region and when?
Which body region and when?
Which body region and when?
Which body region and when?
Which body region and when?
Which body region and when?
Medication
Name / Dosage / Since?
Mandatory field Do you take blood thinners?*
no
jes
Nutritional profile
Mandatory field Do you eat regular?*
Yes
No
Mandatory field When do you have your main meal?*
morning
noon
evening
Mandatory field Breakfast*
Mandatory field Lunch*
Mandatory field Dinner*
Snacks
Mandatory field Drinking behavior*
Stimulants
specify / number
specify / glasses per day
cups per day
Do you suffer from food allergies or food intolerances?
Which?
Which?
Autonomic nervous system
Mandatory field Thirst*
normal
increased
Mandatory field Appetite*
normal
increased
Mandatory field Bowel movement*
normal
increasted
diarrhea
diarrhea with blood
diarrhea with mucus
Mandatory field Urinating*
normal
increased
„burning“
weak voiding stream
nighttime more than 1-2
Mandatory field Difficulty falling asleep*
No
Yes
Mandatory field Maintaining sleep*
No
Yes
Mandatory field Snoring*
No
Yes
Mandatory field Apnoe/respiratory failure:*
No
Yes
Mandatory field Night sweats*
No
Yes
Mandatory field Morning fatigue:*
No
Yes
Weight
constant
not constant
For women
Regular cycle:
No
Yes
Birth control pills:
No
Yes
Menopause:
No
Yes
Are you pregnant?
No
Yes
Yes, which week?
Last gynecological examination
Movement
If yes, how often every week?
What kind of exercise/sport?
Height (cm)
Weight (kg)
Family history
Father
Thyroid disease
Stroke
Diabetes
High blood pressure
Obesity
Elevated blood lipid values
Mental illness
Alzheimer/Dementia
Cardiovascular and vascular diseases
Lung diseases
Cancer
Other
Mother
Thyroid disease
Stroke
Diabetes
High blood pressure
Obesity
Elevated blood lipid values
Mental illness
Alzheimer/Dementia
Cardiovascular and vascular
Lung diseases
Cancer
Other
Mood/emotions
Mood / emotions
good mood
happy
depressed
aggressive
balanced
lonely
sad
exhausted
Pain history
Mandatory field Do you have often pain?*
No
Yes
How long do you have this pain?
How often do you have this pain currently?
daily
weekly
monthly
Has the pain character changed?
improved
worse
steady
Do you get in touch with the pain with a specific event or activity in connection?
How do you treated the pain so far?
Personal health goals
How do you want to get your results?
Paper
electronic: USB-Stick
per E-Mail
Send