Questionnaire (English)
Dear patient, to offer u a complete individually adapted medicine, it is important that you answer as many question as possible.
Questionnaire of Mrs./ Mr./ child/ academic degree:
Date of birth:
Address:
Postal code + City/ town:
Email:
Private phone number:
Phone number at work:
Health insurance:
Level of education?
What do you do for a living?
Courant complaints? (when, where, how often, specific occasions, what did u try already to improve the complaints)
Preceding illnesses?
Operations?
Accidents?
Injuries to the spinal column or to the head?
Whiplash injury?
Scars?
Allergies?
--hay fever? ( trees, grass)
--dust?
--certain nutrients?
--animals
Illnesses/ symptoms of the mother?
Illnesses/ symptoms of the father?
Illnesses/ symptoms of the grandmother (at mother’s side of the family)?
Illnesses/ symptoms of the grandmother (at father’s side)?
Illnesses/ symptoms of the grandfather ( at mother’s side)?
Illnesses/ symptoms of the grandfather (at father’s side)?Illnesses/ symptoms of own children (if present)?
Medication/ Dietary supplements?
--Which products? 1. 2. 3. 4.
--Dose? 1. 2. 3. 4.
--Frequency? 1. 2. 3. 4.
--since when? 1. 2. 3. 4.
Herbs/ Herbal teas/ medication?
Do u smoke? _________ since when?
How much?
What?
Other drugs?
Alcohol?
How frequent in a week?
How much?
Were you breastfed?_________ How long?
How was the own pregnancy? Any peculiarities?
How was the own birth?
When did you grow your first teeth?
When did you start speaking?
When did you start walking?
Psyche:
Lack of drive?
Depression?
Restlessness?
Problems of concentration?
Memory disorders??
Anxieties ( scared of heights, darkness, animals, tunnels, elevator, strangers, future, exams, worries about health, children, family, parents….?
Strains at the workplace?
Strains in the relationship/ with your partner/ partner search?
Strains in the family?
Strains with friends?
Hobbies:
Description oft he workplace?
Scin:
Rash?
Neurodermitis?
Cradle cap?
Herpes simplex?
Warts?
Nosebleeds?
Aphthous ulcers?
Tears/ bursts in between the toes?
Tears/ bursts at fingertips?
Tears/ bursts in the corners of your mouth?
Tears/ bursts in your nose?
A lot of callus?
Easily bruised?
Dry skin?
Psoriasis?
Can you handle sheep wool on your skin?
Dry hair?
Greasy hair?
Greasy skin?
Moles?
How often did you go a tanning salon?
Allergy for nickel?
Nails:
Do they break easily, are they fragile?
spots?
Fungal infection of the nail?
--Where?
--How much?
Hair
Loss?
--Diffuse
--Regionally
--Localization
Fragile hair?
Ears
Tinnitus, ear noises?
Reduces hearing?
Ear pain?
Cracking in the ears?
A lot of earwax?
Itching?
Dizziness?
Tears/bursts behind the ears?
Inflamed ear holes?
Headache
Migraine?
--How often each month?
--With vomiting?
--With visual problems?
--With nausea?
--With diarrhea ?
--With other neurological disturbances?
Headaches?
--How often each week?
Is sun on the head a problem?
Nose
sinuses?
Allergy?
Snoring?
Sneezing?
Slime/ mucus?
Crusts?
How is the humidity in per cent?
--in your house?
--On your job?
--how often do you drive a car, each day?
Eyes
Dry eyes?
tears?
Visual disturbances?
Cataract?
Glaucoma?
Last investigation of eye pressure?
Last eye background investigation?
Itching?
Contact lenses?
Mouth/ throat
Dead teeth?
Inflammations of the roots of your teeth?
Inflammations of the gums?
Aphthous ulcer/ canker sore?
Metals:
--Amalgam?
--Gold?
--Palladium?
--Titanium?
--Plastics?
--Ceramic(s)?
--Implants?
Root end surgery/ apicoectomy?
Smelly breath?
Coated tongue?
strange taste in your mouth?
-- no special taste, often sour taste, often bitter taste, often rotten taste, often bloody taste?
Thyroid:
Enlargement?
Inflammation?
Cysts?
Knots?
Anti-body?
Autoimmune illnesses?
Can you stand closely fitting clothes around the neck?
Thorax:
Cough?
--Acutely?
--Chronically?
Hoarseness?
Weak immune system/ often ill?
Asthma?
--Allergic?
--asthma through strain?
Pain?
--when breathing?
--when doing an effort?
--after a meal?
--when upset/ through anger?
Heart/circulatory system:
Blood pressure?
Pulse?
Palpitation?
tachycardia?
Heart passes?
Nutrition:
How tall are you?
How much do you weigh?
BMI?
mass of fat?
How often do you eat fruit/drink fresh fruit juices? per week: ______________
Which fruits?
How often do you eat salad (raw vegetables)? Per week: ______________
Which salads/raw vegetables?
How often do you eat vegetables/drink vegetable juices? Per week: ______________
Which vegetables?
How often do you eat full grain products? Per week: ______________
Vegetarian?
How often do you eat sausage/cold cuts? Per week: ______________
How often meat? Per week: ______________
How often fish? Per week: ______________
How often fried meals? Per week: ______________
How many eggs a week?
How often nuts? Per week: ______________
What kind of oil do you use? ______________
Do you eat butter or margarine? ______________
How often milk products? Per day: __________Pro week: ______________
Which kinds of milk products? ______________
How often alcohol? ______________
What kind of alcohol? ______________
How often do you drink soft drinks? Per week: ______________
How often do you eat light-products? Per week: ______________
How often do you eat candy or sugar? Per week: ______________
How often do you consume diabetic products? Per week: ______________
How often do you use sugar substitutes? Per week: ______________
Which other beverages? ______________
--Total liquid quantity per day (all beverages together) ______ liters?
--Do you drink at night? ______________
--Black tea, quantity? ______________
--Green tea, quantity? ______________
--Coffee, quantity? ______________
Do you chew sugar-free chewing gum?
Do food do you like in particular? ______________
Which food don't you like at all? ______________
Which food you can’t because you have a bad physical reaction afterwards? ______________
Food allergies?
Do symptoms appear after the consumption of:
-- Bread, muesli, potatoes, rice, noodles? Gluten-intolerance?
-- Hard cheese, Emmentaler-cheese, red wine, tuna, sauerkraut or salami? Histamine intolerance?
-- Sugar substitutes, diabetic food, dietary products and/or artificially sweetened foods?
-- Milk or milk products? Lactose intolerance?
-- Fruit, fruit juices, soft drinks? Fructose-intolerance?
Stomach/ intestines
Frequency of defecation/stool? ______ x/day ________x/week
Did the frequency change?
Stool mostly is: Hard - normal - soft/porridge-alike - like sheep excrements (dark pellets) - sticky? Color of the stool? Dark - brown - light brown - yellowish - greenish - reddish - black?
Does the stool contain impurities? slime - blood - indigested food - pus?
Stomach pain?
Irritable bowel syndrome/ spastic colon?
flatulence’s?
abdominal pain?
--spreads as far as the back or shoulder?
--spreads as far as underneath the navel following the beltline
--in the right lower abdominal region
--immediately after the meal?
--20 min. after the meal?
--1 hr. after the meal?
--when?: in the morning? during the day? at night? On an empty stomach?
--during the meal?
Hemorrhoids ?
Anal fissures/tears?
Fistulae?
Loss of appetite?
Nausea? _______________ before? During? After the meal? Better with meals?
vomiting?
heartburn?
Abdominal fullness? ____________if so, where?
Pot belly?
Burps/ructus?
--how do the burps taste? like nothing, often sourly, often bitterly, often rotten, often like blood?
--How is the smell? (bad, rotten, sour, like fish, like rotten eggs, odorless)
Rumbling stomach/noises in the belly/stomach?
Blood in/after stool?
slime in the stool?
Do you have or did you ever have worms or other parasites?
--Do they have pets?
--did you go on vacation to a foreign country?
Urinary Bladder
Inflammations?
Urinary incontinence ?
--while coughing?
--while laughing?
--while jumping?
urge to urinate?
--during the day ___________times
--At the night? _______ times
Kidney:
Stones?
Inflammations?
cysts?
Gynecology:
(vaginal) discharge?
menstruation: more than every 2 weeks___every 2 weeks___every 3 weeks___every 4 weeks
every 5 weeks___every 6 weeks___less than every 6 weeks___ irregularly ___no menstruation
How many days do you experience strong bleeding? _____How many days mild bleeding?_______
Do you experience intermediate bleeding?
Recurring infections?
Unfulfilled child wish?
Date of the last menstruation?
Symptoms or complaints about the breasts?
breast pain/breast swelling before menstruation?
Psychological complaints due to menstruation?
Do you use birth control? ___________since when?
IUD with progestogen or intrauterine system (IUS)? ___________since when?
IUD without progestogen ___________since when?
Prostate
Inflammations?
Unfulfilled child wish?
Phimosis or inflammations of the urethra?
Sexuality/libido:
Libido is normal?
Libido is increased?
Libido is decreased?
Complaints before/during/after sexual intercourse?
Musculoskeletal system:
Arthrosis: _____________________which joints? _______________________________
____1 joint_____2 joints____3 joints____> 3 joints
Cold hands?
Cold feet?
hot hands?
hot feet?
Trembling?
Hypotonia?
Feeling of numbness?
Tingling feelings?
spasms in the legs?
Growth pains?
Varicose veins?
Tingling?
numbness?
Sleep:
Falling asleep:
Fast _ _ < 15 min. ___< 30 min. ___< 45 min. ___ < 60 min. ___< 90 min___< 120 min
Sleeping through the night: ___0 x awake___1 x awake___2 x awake___3 x awake___> 3 x awake
snoring?
Pauses in breathing/ sleep apnea?
Salivation while sleeping?
Favorite sleeping position?
Grinding teeth?
Sleepwalking?
Does the moon have influence on you?
Sweating during the night?
Dreamlessness?
Do you put your feet outside the bed?
Nightmares?
Do you have electrical appliances in the bedroom?
--Which one’s?
Metabolism:
gout?
Diabetes mellitus type 1?
Diabetes mellitus type 2?
Energy:
Generally feeling cold easily?
Generally much body warmth?
Draft/draught sensitivity?
desperate need for fresh air?
Sweat?:
--Fast? _________not at all?
--Where? ____________________armpits? _________feet? _________at night?
--sweat smell? : ................................. what does the sweat smell like? .........................
The sun:
--I can stand it well? _______________can’t stand it?
Spring complaints?
Summer complaints?
Autumn complaints?
Winter complaints?
Big need for fresh air?
Climate/whether sensitivity?
In the mountains I feel: better – the same -- worse
At the sea I feel: better – the same -- worse
Times of day in which I feel fit:
Times of day in which I feel tired/weak :
Energy: How many percent of your “normal energy level” do you currently have at your disposal?
< 10%
< 20%
< 30%
< 40%
< 50%
< 60%
< 70%
< 80%
< 90%
< 95%
100 %
Sports:
--Which sports?
--How often per week?
--How long?
Sauna: __________How often per week?
Yoga: __________ how often per week?
Meditation: ______How often per week?
Immune system:
How often do you have infections?
Allergic?
--for?
--for?
When did you have a fever the last time? __________How often per year?
When did you have fever the last time?
Inoculations:
Last Tetanus inoculation:
Last Polio inoculation:
Last hepatitis A inoculation:
Last hepatitis B inoculation:
Last yellow fever inoculation:
Last whooping cough inoculation:
Last tick borne encephalitis inoculation:
Other inoculation?
Did you have perceptible reactions to those inoculation?
Inoculation reaction? (redness, swelling, pus, tiredness, weakness, infections, fever, ........)
Laboratory:
Cholesterol values? - increased? ____________-normal? _________________
Liver values? - increased? ____________-normal? _________________
Iron deficiency?
Magnesium deficiency?
Calcium deficiency?
Zinc deficiency?
Selenium deficiency?
Vit D deficiency?
Vit B deficiency?
Other deficiencies?
