QUESTIONNAIRE

Please fill in this questionnaire and we can prepare your personal weekly plan and select the procedures/treatmnts that are most suitable for you.

Name *

Age *

Sex *

Health data

Surgery less than 1 year ago *

Comments: when / what?

Surgery more than 1 year ago *

Comments: when / what?

Artificial Joints *

Comments: when / what?

Pacemaker *

Comments: when / what?

Allergies *

Comments: when / what?

Headaches *

Comments: when / what?

Tumours *

Comments: when / what?

Varicose veins *

Comments: when / what?

High blood pressure *

Comments: when / what?

Acute viral infection/cold (currently runny nose, cough, fever) *

Comments: when / what?

Respiratory diseases (bronchitis, asthma) *

Comments: when / what?

Skin diseases *

Comments: when / what?

Kidney diseases *

Comments: when / what?

Osteoporosis *

Comments: when / what?

Jaundice *

Comments: when / what?

Diseases of the thyroid *

Comments: when / what?

Other

Do you have a disability? *

Comments: when / what?

Do you take food additives? *

Comments: when / what?

Are you on any medications? *

Comments: when / what?

Does your daily work environment cause you tension? *

Comments: when / what?

Does your daily living environment cause you tension? *

Comments: when / what?

Do you exercise (sport)? *

Comments: when / what?

Do you smoke? *

Comments: when / what?

How often do you drink light (up to 5%) alkohol? *

Comments: when / what?

How often do you drink strong (over 5%) alkohol? *

Comments: when / what?

Additional information

Confirmation *

I confirm that the answers are correct, I have not withold any information and that I am aware of the risks of smoking during fasting