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)