Questionnaire

If you complete the confidential questionnaire below, you will receive a free personal advice with a brief explanation.
Once you have completed the questionnaire and selected send, you will receive a confirmation of receipt from us by e-mail.
If you have not received an e-mail confirmation, we have not received the questionnaire.
If you have not received any advice after 8 days, please contact us at 0495 564321 or rob@threewells.nl

Personal Information

First Name *

Last Name *

Date of birth

Address

House number

Zip code

City

E-mail address *

Telephone number

Gender

Attending physician

Length (in cm)

Weight (in kg)

Occupation - Daily activity

Medication/Supplements/Therapy

Diagnosis

My three main complaints are

Vaccinated against Covid-19

Covid-19 symptoms (briefly describe)

Complaints during Covid-19 vaccination, complaints during / just after vaccination, long covid, complaints after infection.

Contact method *

I would like free proposal by e-mail
I would like a free 10 minute telephone consultation with advice
I would like a telephone consultation with more explanation and advice (after 10 minutes €20,= per 15 minutes)

1. General condition

I have enough energy

N/A / don't know
Not
Sometimes
More often
Always

My immune system is working well

N/A / don't know
Not
Sometimes
More often
Always

I am a satisfied person

N/A / don't know
Not
Sometimes
More often
Always

I suffer from excessive stress

N/A / don't know
Not
Sometimes
More often
Always

Actually, I ask too much of myself and get complaints because of this

N/A / don't know
Not
Sometimes
More often
Always

I enjoy life

N/A / don't know
Not
Sometimes
More often
Always

Spirituality has my interest

N/A / don't know
Not
Sometimes
More often
Always

I suffer from pain(s)

N/A / don't know
Not
Sometimes
More often
Always

I have a chronic condition

N/A / don't know
Not
Sometimes
More often
Always

I suffer from headaches

N/A / don't know
Not
Sometimes
More often
Always

I exercise and exercise enough

N/A / don't know
Not
Sometimes
More often
Always

I suffer from infections

N/A / don't know
Not
Sometimes
More often
Always

I suffer from allergies / intolerances

N/A / don't know
Not
Sometimes
More often
Always

I suffer from unwanted weight loss

N/A / don't know
Not
Sometimes
More often
Always

I suffer from unwanted weight gain

N/A / don't know
Not
Sometimes
More often
Always

I have problems with my skeleton / joints / tendons / ligaments

N/A / don't know
Not
Sometimes
More often
Always

I'm a bad sleeper with no sleeping tablets

N/A / don't know
Not
Sometimes
More often
Always

I suffer from heart and/or blood vessels

N/A / don't know
Not
Sometimes
More often
Always

I have problems with my digestive system

N/A / don't know
Not
Sometimes
More often
Always

I have skin problems

N/A / don't know
Not
Sometimes
More often
Always

I have a good hormone balance

N/A / don't know
Not
Sometimes
More often
Always

I have had all vaccinations

N/A / don't know
Not
Sometimes
More often
Always

I have had Pfeiffer's disease / have been tested for it

N/A / don't know
Not
Sometimes
More often
Always

I use drugs

N/A / don't know
Not
Sometimes
More often
Always

My tonsils are cut

N/A / don't know
Not
Sometimes
More often
Always

I have a history of ear infections

N/A / don't know
Not
Sometimes
More often
Always

2. Sleep

I have trouble falling asleep

N/A / don't know
Not
Sometimes
More often
Always

I wake up at night

N/A / don't know
Not
Sometimes
More often
Always

I'm fit when I get up in the morning

N/A / don't know
Not
Sometimes
More often
Always

I suffer from a morning mood

N/A / don't know
Not
Sometimes
More often
Always

Average sleep duration per night

4 hours
6 hours
8 hours
10 hours
12 hours

I have irregular shifts

N/A / don't know
Not
Sometimes
More often
Always

I dream a lot

N/A / don't know
Not
Sometimes
More often
Always

I suffer from nightmares (panic attacks)

N/A / don't know
Not
Sometimes
More often
Always

I toss and turn a lot

N/A / don't know
Not
Sometimes
More often
Always

I have the feeling that something/someone is/will be in my room

N/A / don't know
Not
Sometimes
More often
Always

3. Digestion

I eat healthy

N/A / don't know
Not
Sometimes
More often
Always

I suffer from binge eating

N/A / don't know
Not
Sometimes
More often
Always

I suffer from food intolerances

N/A / don't know
Not
Sometimes
More often
Always

I eat a lot of snacks

N/A / don't know
Not
Sometimes
More often
Always

I drink 1 to 1.5 liters of water daily

N/A / don't know
Not
Sometimes
More often
Always

I drink more than 15 glasses of alcohol a week

N/A / don't know
Not
Sometimes
More often
Always

I like to eat sweets

N/A / don't know
Not
Sometimes
More often
Always

I eat/drink a lot of dairy products

N/A / don't know
Not
Sometimes
More often
Always

I have irregular bowel movements

N/A / don't know
Not
Sometimes
More often
Always

I have regular bowel movements 1 to 2 times a day

N/A / don't know
Not
Sometimes
More often
Always

I suffer from constipation

N/A / don't know
Not
Sometimes
More often
Always

I suffer from gastrointestinal tracts after eating

N/A / don't know
Not
Sometimes
More often
Always

I suffer from abdominal pain / cramps after eating

N/A / don't know
Not
Sometimes
More often
Always

I'm very tired after eating

N/A / don't know
Not
Sometimes
More often
Always

I suffer from abdominal cramps

N/A / don't know
Not
Sometimes
More often
Always

I suffer from diarrhea

N/A / don't know
Not
Sometimes
More often
Always

I am a vegetarian

N/A / don't know
Not
Sometimes
More often
Always

I have hard stools

N/A / don't know
Not
Sometimes
More often
Always

I suffer from non-smelling flatulence

N/A / don't know
Not
Sometimes
More often
Always

My stool is a nice turd

N/A / don't know
Not
Sometimes
More often
Always

My stool looks shabby

N/A / don't know
Not
Sometimes
More often
Always

My stool has a light yellow color

N/A / don't know
Not
Sometimes
More often
Always

My stool is dark brown

N/A / don't know
Not
Sometimes
More often
Always

My stool is black

N/A / don't know
Not
Sometimes
More often
Always

I suffer from heartburn

N/A / don't know
Not
Sometimes
More often
Always

I have a white deposit on my tongue

N/A / don't know
Not
Sometimes
More often
Always

I have blood/mucus in my stool

N/A / don't know
Not
Sometimes
More often
Always

I am sensitive to alcohol

N/A / don't know
Not
Sometimes
More often
Always

I suffer from hemorrhoids

N/A / don't know
Not
Sometimes
More often
Always

I suffer from pinworms

N/A / don't know
Not
Sometimes
More often
Always

I suffer from rectal itching

N/A / don't know
Not
Sometimes
More often
Always

I like to eat sour things

N/A / don't know
Not
Sometimes
More often
Always

I tend to put objects in my mouth

N/A / don't know
Not
Sometimes
More often
Always

4. Blood flow

I suffer from cold hands more often (more often every 4 weeks)

N/A / don't know
Not
Sometimes
More often
Always

I suffer from cold feet

N/A / don't know
Not
Sometimes
More often
Always

I often feel cold

N/A / don't know
Not
Sometimes
More often
Always

I suffer from intermittent claudication

N/A / don't know
Not
Sometimes
More often
Always

My blood pressure is ok

N/A / don't know
Not
Sometimes
More often
Always

I am being treated by a specialist for my heart and blood vessels

N/A / don't know
Not
Sometimes
More often
Always

I suffer from reduced blood flow

N/A / don't know
Not
Sometimes
More often
Always

I have had surgery on my heart and/or blood vessels

N/A / don't know
Not
Sometimes
More often
Always

I am taking medication for my blood pressure/blood vessels

N/A / don't know
Not
Sometimes
More often
Always

I suffer from swollen feet and/or legs

N/A / don't know
Not
Sometimes
More often
Always

I suffer from chest pressure

N/A / don't know
Not
Sometimes
More often
Always

I suffer from varicose veins

N/A / don't know
Not
Sometimes
More often
Always

I suffer from migraines

N/A / don't know
Not
Sometimes
More often
Always

I am easily short of breath with light exertion

N/A / don't know
Not
Sometimes
More often
Always

I bruise easily

N/A / don't know
Not
Sometimes
More often
Always

5. Brain and behavior

I can't keep my legs or one leg still (restless leg)

N/A / don't know
Not
Sometimes
More often
Always

I have trouble reading

N/A / don't know
Not
Sometimes
More often
Always

I suffer from mood swings

N/A / don't know
Not
Sometimes
More often
Always

I often feel misunderstood

N/A / don't know
Not
Sometimes
More often
Always

I'm having trouble with my long-term memory

N/A / don't know
Not
Sometimes
More often
Always

I have trouble with my short-term memory

N/A / don't know
Not
Sometimes
More often
Always

I'm struggling to get my words out

N/A / don't know
Not
Sometimes
More often
Always

I suffer from seizures or convulsions

N/A / don't know
Not
Sometimes
More often
Always

I have a developmental delay

N/A / don't know
Not
Sometimes
More often
Always

I have a conduct disorder

N/A / don't know
Not
Sometimes
More often
Always

I want to constantly repeat actions (persevering)

N/A / don't know
Not
Sometimes
More often
Always

I am very restless

N/A / don't know
Not
Sometimes
More often
Always

I suffer from tics / nervous twitches

N/A / don't know
Not
Sometimes
More often
Always

I have unclear handwriting

N/A / don't know
Not
Sometimes
More often
Always

I can't do mental arithmetic very well

N/A / don't know
Not
Sometimes
More often
Always

I have trouble making/maintaining friendships

N/A / don't know
Not
Sometimes
More often
Always

I have trouble getting along with others

N/A / don't know
Not
Sometimes
More often
Always

I like to isolate myself

N/A / don't know
Not
Sometimes
More often
Always

I find it difficult to make eye contact

N/A / don't know
Not
Sometimes
More often
Always

I show little emotion (laughing, crying)

N/A / don't know
Not
Sometimes
More often
Always

I can't empathize with the other person (empathy)

N/A / don't know
Not
Sometimes
More often
Always

I have a tendency to self-harm (hurting myself)

N/A / don't know
Not
Sometimes
More often
Always

I can be extremely frustrated

N/A / don't know
Not
Sometimes
More often
Always

I suffer from tantrums, outbursts of anger

N/A / don't know
Not
Sometimes
More often
Always

I suffer from trauma

N/A / don't know
Not
Sometimes
More often
Always

When I am angry / frustrated / furious I find it difficult to let go of this

N/A / don't know
Not
Sometimes
More often
Always

I have a positive attitude and cheerfulness

N/A / don't know
Not
Sometimes
More often
Always

I can't handle tensions well

N/A / don't know
Not
Sometimes
More often
Always

I suffer from depression

N/A / don't know
Not
Sometimes
More often
Always

I suffer from anxiety

N/A / don't know
Not
Sometimes
More often
Always

I suffer from panic attacks

N/A / don't know
Not
Sometimes
More often
Always

I like to stick to fixed patterns

N/A / don't know
Not
Sometimes
More often
Always

I have an extremely high pain threshold

N/A / don't know
Not
Sometimes
More often
Always

I have trouble expressing my own opinion

N/A / don't know
Not
Sometimes
More often
Always

I am constantly looking for stimuli

N/A / don't know
Not
Sometimes
More often
Always

I find it difficult to relax

N/A / don't know
Not
Sometimes
More often
Always

6. Skin

I have poor wound healing

N/A / don't know
Not
Sometimes
More often
Always

I have troubled skin

N/A / don't know
Not
Sometimes
More often
Always

I have skin complaints

N/A / don't know
Not
Sometimes
More often
Always

I suffer from dermatitis (eczema)

N/A / don't know
Not
Sometimes
More often
Always

I often have red blushes on cheeks and red ears

N/A / don't know
Not
Sometimes
More often
Always

I suffer from psoriasis

N/A / don't know
Not
Sometimes
More often
Always

I suffer from dry skin

N/A / don't know
Not
Sometimes
More often
Always

I suffer from water warts

N/A / don't know
Not
Sometimes
More often
Always

I suffer from shingles

N/A / don't know
Not
Sometimes
More often
Always

I suffer from acne

N/A / don't know
Not
Sometimes
More often
Always

I bruise easily

N/A / don't know
Not
Sometimes
More often
Always

I suffer from an allergic skin reaction

N/A / don't know
Not
Sometimes
More often
Always

I suffer from warts

N/A / don't know
Not
Sometimes
More often
Always

I suffer from dandruff

N/A / don't know
Not
Sometimes
More often
Always

I suffer from an itchy scalp

N/A / don't know
Not
Sometimes
More often
Always

I suffer from extreme hair loss

N/A / don't know
Not
Sometimes
More often
Always

I suffer from head lice

N/A / don't know
Not
Sometimes
More often
Always

I suffer from recurring wounds / inflammations

N/A / don't know
Not
Sometimes
More often
Always

7. Nails

I have brittle, easily breaking nails

N/A / don't know
Not
Sometimes
More often
Always

I have very thin sensitive nails

N/A / don't know
Not
Sometimes
More often
Always

I have white dots in the nails

N/A / don't know
Not
Sometimes
More often
Always

I suffer from fungal nails (fungal nails)

N/A / don't know
Not
Sometimes
More often
Always

My nails are not evenly smooth (ridges)

N/A / don't know
Not
Sometimes
More often
Always

8. Fluid Balance and Urinary Health

I suffer from recurring bladder infections

N/A / don't know
Not
Sometimes
More often
Always

I suffer from strong odorous perspiration

N/A / don't know
Not
Sometimes
More often
Always

I suffer from heavy perspiration

N/A / don't know
Not
Sometimes
More often
Always

I suffer from urine leakage

N/A / don't know
Not
Sometimes
More often
Always

I have a powerful urine stream

N/A / don't know
Not
Sometimes
More often
Always

I suffer from incontinence / urine leakage

N/A / don't know
Not
Sometimes
More often
Always

I suffer from bedwetting

N/A / don't know
Not
Sometimes
More often
Always

I have to get up at night to pee

N/A / don't know
Not
Sometimes
More often
Always

I have to urinate more than 5 times a day

N/A / don't know
Not
Sometimes
More often
Always

My urine stream is very variable

N/A / don't know
Not
Sometimes
More often
Always

I have the urge to urinate more often but then there is little urine

N/A / don't know
Not
Sometimes
More often
Always

I have erection problems

N/A / don't know
Not
Sometimes
More often
Always

I have problems with my prostate

N/A / don't know
Not
Sometimes
More often
Always

My urine has a strong odor

N/A / don't know
Not
Sometimes
More often
Always

My urine is yellow-orange

N/A / don't know
Not
Sometimes
More often
Always

I have irregular periods

N/A / don't know
Not
Sometimes
More often
Always

I suffer from extreme bleeding during menstruation

N/A / don't know
Not
Sometimes
More often
Always

I have a lot of complaints during my period

N/A / don't know
Not
Sometimes
More often
Always

I suffer from bladder stones

N/A / don't know
Not
Sometimes
More often
Always

I have pain while urinating

N/A / don't know
Not
Sometimes
More often
Always

I suffer from vaginal discharge

N/A / don't know
Not
Sometimes
More often
Always

I have menopausal symptoms (meno break)

N/A / don't know
Not
Sometimes
More often
Always

I suffer from endometriosis (adhesions of inflamed uterus)

N/A / don't know
Not
Sometimes
More often
Always

I suffer from kidney stones and/or gallstones

N/A / don't know
Not
Sometimes
More often
Always

9. Skeletal-Tendons-Muscles-Ligaments-Joints

in the morning when I get up I have stiff joints, after that it goes better

N/A / don't know
Not
Sometimes
More often
Always

After sitting still for a while, my joints are stiff

N/A / don't know
Not
Sometimes
More often
Always

I suffer from cramps

N/A / don't know
Not
Sometimes
More often
Always

I have pain in joints

N/A / don't know
Not
Sometimes
More often
Always

If I pull on the tip of my finger, I can pull it out of the joint a bit

N/A / don't know
Not
Sometimes
More often
Always

When I pull on the hand, the wrist joint stretches a bit

N/A / don't know
Not
Sometimes
More often
Always

I easily go through my ankles

N/A / don't know
Not
Sometimes
More often
Always

I have problems with my hip(s) while walking

N/A / don't know
Not
Sometimes
More often
Always

When I move my head from left to right, it grinds a bit in the neck

N/A / don't know
Not
Sometimes
More often
Always

My muscles tendons ligaments are more often "under tension"

N/A / don't know
Not
Sometimes
More often
Always

I suffer from back problems

N/A / don't know
Not
Sometimes
More often
Always

I had hip surgery

N/A / don't know
Not
Sometimes
More often
Always

I suffer from neck pain

N/A / don't know
Not
Sometimes
More often
Always

It "snaps" in joints/back

N/A / don't know
Not
Sometimes
More often
Always

I have swollen joints

N/A / don't know
Not
Sometimes
More often
Always

I have fused joints

N/A / don't know
Not
Sometimes
More often
Always

I have pain in the bones

N/A / don't know
Not
Sometimes
More often
Always

I suffer from bursa

N/A / don't know
Not
Sometimes
More often
Always

I've had a dislocated arm

N/A / don't know
Not
Sometimes
More often
Always

I have had serious injuries / an accident and suffer from this

N/A / don't know
Not
Sometimes
More often
Always

I have a whiplash like injury

N/A / don't know
Not
Sometimes
More often
Always

I suffer from gout

N/A / don't know
Not
Sometimes
More often
Always

I have RSI/tennis elbow/heel spur/carpatial tunnel syndrome injury

N/A / don't know
Not
Sometimes
More often
Always

I suffer from rheumatism

N/A / don't know
Not
Sometimes
More often
Always

I suffer from osteoarthritis

N/A / don't know
Not
Sometimes
More often
Always

I suffer from arthritis

N/A / don't know
Not
Sometimes
More often
Always

I suffer from joint wear

N/A / don't know
Not
Sometimes
More often
Always

I suffer from "trigger finger"

N/A / don't know
Not
Sometimes
More often
Always

My knees are bothering me

N/A / don't know
Not
Sometimes
More often
Always

I walk (physically) on my toes (high muscle tension)

N/A / don't know
Not
Sometimes
More often
Always

10. Senses

My sense of smell works well

N/A / don't know
Not
Sometimes
More often
Always

I am sensitive to certain smells

N/A / don't know
Not
Sometimes
More often
Always

I suffer from my sinuses and sinuses

N/A / don't know
Not
Sometimes
More often
Always

I suffer from my runny nose

N/A / don't know
Not
Sometimes
More often
Always

I drool

N/A / don't know
Not
Sometimes
More often
Always

My taste buds are working well

N/A / don't know
Not
Sometimes
More often
Always

I suffer from cold sores

N/A / don't know
Not
Sometimes
More often
Always

I suffer from cracked and painful mouth and lips

N/A / don't know
Not
Sometimes
More often
Always

I suffer from teeth grinding

N/A / don't know
Not
Sometimes
More often
Always

I have a white rash on my tongue

N/A / don't know
Not
Sometimes
More often
Always

I have a thick tongue or little feeling in my tongue

N/A / don't know
Not
Sometimes
More often
Always

My hearing is good

N/A / don't know
Not
Sometimes
More often
Always

I suffer from earache

N/A / don't know
Not
Sometimes
More often
Always

I suffer from tinnitus

N/A / don't know
Not
Sometimes
More often
Always

I have a history of ear infections and/or tubes

N/A / don't know
Not
Sometimes
More often
Always

I suffer from dizziness and/or have difficulty keeping my balance

N/A / don't know
Not
Sometimes
More often
Always

My eyes are good

N/A / don't know
Not
Sometimes
More often
Always

I suffer from red eyes

N/A / don't know
Not
Sometimes
More often
Always

I suffer from itching behind my eyes

N/A / don't know
Not
Sometimes
More often
Always

I suffer from inflamed eyes

N/A / don't know
Not
Sometimes
More often
Always

I have dry eyes

N/A / don't know
Not
Sometimes
More often
Always

I suffer from night blindness

N/A / don't know
Not
Sometimes
More often
Always

I am sensitive to light

N/A / don't know
Not
Sometimes
More often
Always

I have macular degeneration

N/A / don't know
Not
Sometimes
More often
Always

I see double

N/A / don't know
Not
Sometimes
More often
Always

I suffer from clouded eye lenses (cataracts, cataracts)

N/A / don't know
Not
Sometimes
More often
Always

I suffer from clouded eyeball

N/A / don't know
Not
Sometimes
More often
Always

I suffer from nerve pains

N/A / don't know
Not
Sometimes
More often
Always

I have little feeling in my fingers and or skin

N/A / don't know
Not
Sometimes
More often
Always

I am sensitive to touch

N/A / don't know
Not
Sometimes
More often
Always

11. Airways

I have a respiratory disease

N/A / don't know
Not
Sometimes
More often
Always

I have chronically clogged sinuses

N/A / don't know
Not
Sometimes
More often
Always

I have asthma

N/A / don't know
Not
Sometimes
More often
Always

I have bronchitis

N/A / don't know
Not
Sometimes
More often
Always

I suffer from hay fever

N/A / don't know
Not
Sometimes
More often
Always

I suffer from a dry tickling cough

N/A / don't know
Not
Sometimes
More often
Always

I use medication for my airways (possibly puffer)

N/A / don't know
Not
Sometimes
More often
Always

I'm a smoker

N/A / don't know
Not
Sometimes
More often
Always

I suffer from shortness of breath

N/A / don't know
Not
Sometimes
More often
Always

I suffer from wheezing (bronchi)

N/A / don't know
Not
Sometimes
More often
Always

I suffer from stuck mucus

N/A / don't know
Not
Sometimes
More often
Always

General comments

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Synergy Nutriceutica B.V.
Heltenbosdijk 14
6006 RZ Weert
The Netherlands
T: +31 (0)495 56 43 21
E: info@threewells.nl