Health Questionnaire

Please,

1) click on the page and highlight (press Ctrl A)then

2) copy (Ctrl C) the following

Health Questionnaire,

3) then click on iskraharle@yahoo.com and

4) paste (Ctrl V)it inthe email box.

5) Answer the questions and

6) click send.

You will be contacted shortly after your email has been received.

PRIVATE AND CONFIDENTIAL

HEALTH QUESTIONNAIRE

Name* -

E-mail* -
Date of Birth - dd, mm, year -
Time of Birth - h, min. -
Place of Birth - Town, Country -
Place of Residence - Town, Country -
Sex- Male, Female
Ethnic origin - White, Asian, African, Other

1. Name your current illnesses

A) Name of your currentillness/es;

B) When (year, month) did they begin?

C) Explain all of your symptoms and where you have painor discomfort.

Illness1 A -

B -

C -

Illness 2 A -

B -

C -

Illness3 A -

B -

C -

More...

2. Name allof the illnesses you have suffered from; start from your childhood -until now. When did they begin (year, month), how long time etc. -

3. What is your blood pressure, pulse? -

4. What is your cholesterol level? -

5. Which of the following refers to you? - underline the symptoms -

a) fatigue and low energy, feeling cold, dry skin, constipation, a slow pulse and low blood pressure, depression, poor memory, poor concentration,loss of libido, infertility, repeated miscarriages-

b) irritability, anxiety and a pounding heart, you feel hotter than those around you, palpitation, insomnia, breathlessness, increased bowel movement, light or absent menstrual periods, fatigue, trembling hands, muscle weakness, warm moist skin, hair loss, staring gaze-

6. Which of the following refers to you? - Yes or No

- Intolerance to light -

- Bruise easily -

- Skin heals quickly from sores -

- Rheumocardit -

- Cardiovascularinsufficiency -

- Depression -

- Stress -

- Headaches/Migraine

- Fatigue

- Backache

- PMS

- Hemorrhoids

- Constipation

- Diarrhea

- Intestinal cramps

- Abdominal bloated feeling

- Other:

7. Do you have Swelling? - Yes/ No

- If you have Swelling, Where? -

Feet -

Legs -

Under the eyes -

Whole body -

8. Do you smoke? - Yes/ No

If Yes, Select -

Cigarettes

Cannabis

9. Do you use Alcohol? - Yes/ No/ Occasionally

- If Yes, name it (concentrate or weak):

10. Are you dependent on antidepressants or other drugs? - Yes/ No

11. Have you had any

- weight loss

- weight gain

12. Do you treat your illness? - Yes/ No

- If Yes, select from below:

Counselling

Remedial Massage

Yoga

Physiotherapy

Gym

Stretching

Walks

Diet

Sunbathing

13. Name the Medicines you use any to treat your illness (if you use):

14. Are you allergick to wheat products (bread, pizza, pasta), dairy products (milk, joghurt, cheese, feta), peanuts, other.........................

15. Do you eat RAW LIFE FOOD? - Yes/ No/ Occasionally/ Little

Select:

Fresh rawTomatoes

Fresh raw Peppers

Fresh raw Onions

Lettuce

Cucumber

Fresh raw Fruit

Unheated Oil

Unsalted Butter

Honey

Brown Sugar

Wholemeal grains

Feta Cheese

Plain Living Yoghurt

Filtered Water

Herb Tea

Fresh squeezed Fruit or Vegetable Juice

16. Do you eat PROCESSED FOOD - Yes/No/Little

Select:

Cooked vegetables

Meat

Fish

Poultry

Tinned foods

Take away meals

Fried/cooked oil

Margarine

Tinned fruit

White sugar

Sweet products

Sweets

White bread

Biscuits

Cheese

Carbonated drinks

Alcohol

Juice concentrate

Dairy products

Sweet yoghurt

Milk

Ice cream

Milk drinks

Black tea

Coffee

Cola drinks

Carbonated drinks

Energy drinks

17. Determine your pain level

- between 0 and 100%

18. Determine your energy level

- between 0 and 100%

19. How did you find my website?

- Internet search

- Got link from a friend

- Found link on another site

- Saw your ad in a newspaper
- A patient of yours recommended your treatment tome