Questionnaire in connection with first treatment

Please fill out this form and send it by mail:

Health status questionnaire: Download here!


  1. Do you have any diagnoses / diseases:


  1. Are you taking medication:


  1. Have you had surgery and if so, for what?


  1. How is your blood pressure?


  1. Do you have diabetes?


  1. Do you have hepatitis?


  1. Do you have HIV / AIDS?


  1. Do you suffer from asthma?


  1. Do you have eczema or other skin conditions?


  1. Do you have a normal body weight?


  1. Do you smoke?


  1. Do you exercise?


  1. How do you sleep at night? Can you fall asleep? Do you wake up during the night?


  1. Do you sweat at night?


  1. Do you generally feel cold or hot?


  1. Do you have vision, talking or hearing problems?


  1. Do you suffer from headaches? Neck, temple or forehead?


  1. Do you have seizures?


  1. Do you have paralysis? Feeling disorders? Fingers sleeping?


  1. Are you dizzy or fainting?


  1. Do you have heart problems?


  1. Do you have water in your legs?


  1. Do you often have respiratory infections? Cold / pneumonia? COL?


  1. How does your digestion run? Constipation / diarrhea? Nausea? Acid reflux?


  1. Urinary tract problems? Incontinence / cystitis?


  1. How is your menstrual cycle?

  1. Do you have pain in your joints or back? Arthritis? (Joint or wear?) Sciatica? Disc herniation?


  1. Do you have muscle pain / myoses?


  1. Do you have tendonitis? Frozen shoulder? Heel spurs? Tennis elbow? Golf elbow?