Family Name: *
First Name: *
Email *
Phone *
Birth Date/Time:
Profession
Exercise and fitness details
Body weaknesses and injuries
Diseases / Symptoms / Main Concern
Please list out the minerals you take
Please list out the vitamins you take
Please list out these other items
Please list out these other items
Please list out the details
Any other details related to your health?
Please list out the details
Please list out the details
Please list out the details
How many children?
How many pregnancies?
How many live births?
How many abortions?
How many miscarriages?
Please list details
Surgeries in your life
Difficult diseases in your life
Most frequent health issues in your life
All therapies during last 12 months & results you got
Where do you feel these symptoms/pain; are these radiating and, if yes where?
Same question regarding when you feel better and your symptoms are softening.
Please list out details
Please list out details
Please list out details
Which are the diseases you had in the past, which manifested in an acute way, and which healing easily?
Please describe
How many and if possible, which vaccines did you get.
Was there any reaction thereafter, any special symptoms?
Which other diseases, surgeries, special conditions, and therapies did you have and when?
Have you noticed any skin changes, eczemas, which kind, and when?
Were these treated, which therapies were applied?
Do you feel cold or heat more than average?
Do you take your shower warm or cold?
Which are your preferred drinks and food?
List details
Which body zones do you experience sweat? Please list:
Do you see or feel any special reactions or symptoms when excreting stool, urine, period bleeding, sweating?Which body zones do you experience sweat? Please list: (copy)
Do you have anxiety, fears, panic when thunderstorms are occurring, claustrophobia, height fear, small rooms, public speaking, or performing?
Do you dream often, and do you see repeatedly dreams; which are your dreams, do you remember these?
Which are now your major health concerns and targets?