Questionnaire

Patient questionnaire

First name *

Last name

Date of birth

Address

Number

Zip code

City

Country

Email address *

Phone number *

Gender (male/female)

Guiding doctor / therapist

Length (in cm)

Weight (in kg)

Occupation/daily activity

Current medication

Diagnose

Foodsupplements / remedies / therapies

My three most common complaints are:

Vaccinated against covid-19

Yes

No

COVID-19 complaints (summarised):

Complaints during / shortly after COVID-19 vaccination, difficult recovery.

Contact method

I would like a free proposal by email

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)

Patient questionnaire

1. General Condition

2. Sleep

3. Digestive tract

4. Bloodcirculation

5. Brain functions / Emotion balance

6. Skin

7. Nails

8. Urinary tract – sexual organs

9. Musculoskeletelal system

10. Senses

11. Respiratory tract

Remarks

Questionnaire

Patient questionnaire

1. General Condition arrowup6

2. Sleep arrowup6

3. Digestive tract arrowup6

4. Bloodcirculation arrowup6

5. Brain functions / Emotion balance arrowup6

6. Skin arrowup6

7. Nails arrowup6

8. Urinary tract – sexual organs arrowup6

9. Musculoskeletelal system arrowup6

10. Senses arrowup6

11. Respiratory tract arrowup6

Remarks arrowup6

1. General Condition

2. Sleep

3. Digestive tract

4. Bloodcirculation

5. Brain functions / Emotion balance

6. Skin

7. Nails

8. Urinary tract – sexual organs

9. Musculoskeletelal system

10. Senses

11. Respiratory tract

Remarks