Please fill out this form and send it by mail: pernille@lystrup-akupunktur.dk
Health status questionnaire: Download here!
- Do you have any diagnoses / diseases:
- Are you taking medication:
- Have you had surgery and if so, for what?
- How is your blood pressure?
- Do you have diabetes?
- Do you have hepatitis?
- Do you have HIV / AIDS?
- Do you suffer from asthma?
- Do you have eczema or other skin conditions?
- Do you have a normal body weight?
- Do you smoke?
- Do you exercise?
- How do you sleep at night? Can you fall asleep? Do you wake up during the night?
- Do you sweat at night?
- Do you generally feel cold or hot?
- Do you have vision, talking or hearing problems?
- Do you suffer from headaches? Neck, temple or forehead?
- Do you have seizures?
- Do you have paralysis? Feeling disorders? Fingers sleeping?
- Are you dizzy or fainting?
- Do you have heart problems?
- Do you have water in your legs?
- Do you often have respiratory infections? Cold / pneumonia? COL?
- How does your digestion run? Constipation / diarrhea? Nausea? Acid reflux?
- Urinary tract problems? Incontinence / cystitis?
- How is your menstrual cycle?
- Do you have pain in your joints or back? Arthritis? (Joint or wear?) Sciatica? Disc herniation?
- Do you have muscle pain / myoses?
- Do you have tendonitis? Frozen shoulder? Heel spurs? Tennis elbow? Golf elbow?