Name
*
Vorname
Nachname
Birthdate
Email
*
Telephone
Address
*
Your current difficulties, what are you coming to me for?
Was there a trigger for your difficulties? Did you notice anything immediately before your difficulties?
Ex: An illness, grief, sadness, fear, surgery, medication, skin rashes, etc.
What medications are you currently taking?
Any known previous diseases?
Bitte ankreuzen
Any chronic diseases?
When was your last blood work done?
Were any values changed or conspicuous in the last blood count? Which ones?
Do you suffer from recurring headaches?
Do you wear glasses? If so, are you nearsighted or farsighted?
Have you had the following infectious diseases?
Wenn ja, bitte ankreuzen:
Were/are you ill with another infectious disease? (E.g. on vacation)
What are you vaccinated against?
Have you ever had surgery? If yes, when and what?
Do you have any allergies?
Check any that apply:
Please mention any food allergies:
Any other allergies:
What diseases are you aware of in your family?
Check any that apply:
Any other other diseases:
Number of pregnancies
Number of births
Was delivery by cesarean section?
Are you taking the Pill?
Do you use another hormonal contraceptive method? (E.g. implant, Mirena, etc.)
Menstruation:
Are you already in menopause? If yes, since when? Do you suffer from specific complaints?
Height
Weight
Is your body weight stable?
How much do you drink per day and what?
How would you describe your eating habits?
What percentage do meat and meat products make up in your regular diet?
What percentage do animal products make up in your regular diet?
What meals would you consider your main meal?
How are your meals usually prepared?
Do you avoid specific foods for health reasons? If yes, which ones?
Do you have aversions to certain foods?
How is your digestion?
Bitte ankreuzen:
Do you smoke? If yes, how much?
Do you exercise regularly / do you do sports? In what form and how often?
Do you wear a dental device to sleep?
Please describe your sleep patterns
How much time per day do you spend at a screen?
What measures do you take yourself to maintain your health?
