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
