First name

Last name

Birthday

Month

Day

Year

Address

Email

Who recommended me to you?

Profession, education, occupation

Instruction:

Please take your time to fill out this questionnaire correctly. In case of given examples, underlining is enough if they apply; if not, please describe in your own words.

Important!!! Please grade every symptom with a number (1 to 10) regarding its severity, 1 being the least and 10 the strongest and write the number behind the symptom, as well the year you experienced it for the first time. (e.g.: headache 8, 2013)

What are the three main symptoms you are suffering from? What did your physician diagnose?

please bring along your medication, preferably your prescribed daily dose, as well as a panoramic radiography picture of your jawbone.

Are you suffering from pain? (Since when, how intense?)

Were there any accidents (whiplash injury, herniation, fracture, etc.)?

What happened shortly before the first notion of your present symptom(s) (maybe the trigger)? i.e. illness, sorrow, mourning, fright, surgery, exanthema, medicine, etc. ...

Which diseases are known in your family? (Grandparents, parents, siblings) i.e. cancer, tuberculosis, depression, sexually transmitted diseases, suicide, epilepsy, heart disease, vascular disease, stroke, CVA, asthma, diabetes, rheumatism, kidney stones,

Which kind of vaccinations did you receive? Please bring your vaccination card with you. i.e. tuberculosis (BCG), poliomyelitis, diphteria, tetanus, haomophilus influenzae (HIB), pertussis, measles, mumps, rubella, hepatitis, cholera, yellow fever, smallp

Did your body react on any of the forementioned vaccination(s)? i.e. fever, cramps, spasms, restlessness, anxiety, insomnia, change of behavior, etc. ...

Which infectious disease(s) did you suffer from? Measles, mumps, rubella, whooping cough (pertussis), chicken pox, scarlet fever, tetanus, polio, malaria, salmonellosis, dysentery, glandular fever, gonorrhea, syphilis, tropical diseases, tuberculosis, etc

Were these or other diseases ever treated with antibiotics or cortisone? if yes, which ones were used? How often?

Do you suffer from headache? If yes, how often

seldom, forehead - eyes - temple - back of the head (occipital bone), in the morning, in the evening, semi-sided, left, right, double-sided

Trigger of headache

What ameliorates, alleviates the headache?

What deteriorates the headache, makes it worse?

HAIR: circular loss of hair, baldness, dandruff, since when

EYES: conjunctivitis, cataract, myopia, hyperopia, macula degeneration, etc.

EARS: left, right, both - inflammation of the middle ear, hardness of hearing, pain, noise

Teeth/jawbone: -mark with a cross where applicable:

dentition troubles

YES

NO

extraction of wisdom teeth

YES

NO

which one(s)?

root canal treatment

YES

NO

which one(s)?

gingival bleeding, bleeding of gums

YES

NO

any dead teeth

YES

NO

which one(s)?

sensitivity to temperature (hot/cold)

YES

NO

which one(s)?

removal of amalgam fillings

YES

NO

amalgam drainage treatment

YES

NO

what was used for the treatment?.

NOSE: surgery, hay fever, allergic to

TONSILS: surgery, frequent inflammation as a child / presently, sore throat, bad breath

THYROID GLAND: hyperthyroidism, hypothyroidism, surgery, enlargement

MAMMARY GLAND: troubles, discomforts, surgery, lump, cysts, swelling

HEART: problems, twinge, compression, infarct, anxiety, irregular heartbeat, cardiac rhythm disturbances, bypass

BLOOD PRESSURE: last check? Result

LIVER: inflammation - hepatitis, tolerating less alcohol

GALL BLADDER: gall stones, colics, surgery, pressure in the upper abdomen, fat intolerance

STOMACH: feeling of fullness, gastritis, lack of appetite, food allergies, heartburn

INTESTINE: infections, fungal disease, hemorrhoids, appendix surgery, flatulence yes/no smell......

DEFECATION: daily, every 2nd, 3rd, 4th, .... day. Irregular, smells like

tendency toward obstipation, tendency toward diarrhea, excrements are light, dark, bad smelling, hard, pellets, soft, greasy, smeary, paste-like. Feeling of never getting finished, unsteady, variable defecation, etc. Need a lot of toilet paper, toilet brush

KIDNEY/BLADDER: kidney stone, inflammation - frequently, low back pain - left / right

URINE: a lot, sparse, unable to hold, foamy, frothy, smells like

ARMS / LEGS / BACK / SKIN

ARMS: injuries, pains, tennis elbow, itchy or tingling sensation, cold hands, etc.

LEGS: injuries, pains, varicose vains, surgeries, cold feet, pins and needles, numbness, open wounds

BACK: muscle tenseness, rheumatism, pain in cervical/thoracic/lumbar -spine, lumbago, sciatica, scoliosis

SKIN / NAILS: ulcer, itchiness, warts, fungi, nail bed inflammation, eczemas, allergic to (creams etc.)

FEMALE AREA

GYNAECOLOGICAL: vaginal discharge - none, strong, white, yellow, excoriating, tincturing clothes, painful, ovary inflammation, abrasion, miscarriage, childbirth: which year(s). abortion, tumor, cysts, myomas, fungi, sexual diseases, etc.

MENSES: when was the first and the last

menses are light, dark, cloggy, brown

menses are strong, weak, last long

frequence of the menstrual period

problems before - after -during the menstruation

intermenstrual bleedings

Menopausal symptoms

are you using contraceptives? What kind of, and since when

when was your last gynaecologist consultation?

MALE AREA

PROSTATE GLAND: enlarged, inflammation presently/history, problems while urinating, When was your last cancer screening?

GENERAL

where do you have scars? Important!... write down the year, even for the tiniest scar.

Did you ever have a tick bite? (Where?, when?)

Did you gain or lose weight during the last six moths (if "yes", how many kgs, lbs, stones)?

SLEEP: insomnia, frequent awakening at night ( what times), difficulty to fall asleep, talking in your sleep, restlessness in the legs, night sweats, hot feet, gnashing of teeth.

Do you have the sensation of being in rested and relaxed after sleep?

DREAMS: horrified, beautiful, towards the morning time, thoughtful, contemplative, close to reality

TYPE OF SPORTS and how frequent?

NUTRITION: desire for sweet, sour, savory, salty, meat, eggs, fruit, nikotine, alcohol, strong dislike/aversion against sweet, sour, savory, salty, meat, alcohol allergies to

Do you follow any guidelines regarding nutrition, i.e. Vegetarian, vegan, etc. ? if yes, which ones?

SMOKING? if yes, what, how much