Entry Questionnaire

Name

Surname

Email

Telefon

1. Current problem: In a few words, please describe your current problem
What? Where? (Physical location)

How? (Intensity? Characteristic of pain: stinging, throbbing, dizziness? Progress? Since when?)

Cause of condition? (Worsening factors? Improving factors?)

When? (At what times throughout the day?)

2. Medical history: With the following questions we would like to further elaborate on your state of health. Please answer with YES or NO

a) Do you currently or regularly suffer from any of the following conditions:

• YES NO
• Fever YESNO
• Headache YESNO
• Fatique YESNO
• Dizziness YESNO
• Appetite disorder YESNO
• Weight fluctuation (Gain/Loss) YESNO
• Insomnia YESNO
• Frequent perspiration YESNO
• Night sweats YESNO

• Eye problem

  • Impaired vision YESNO
  • Inflammation YESNO
  • Flickering of vision YESNO

• Ear problem

  • Tinnitus YESNO
  • Impaired hearing YESNO
  • Inflammation YESNO
• Flu YESNO

• Skin disorder

  • Rash YESNO
  • Impaired hearing YESNO
• Hair loss YESNO
• Joint problems YESNO
• Backaches YESNO

• Heart conditions

  • Palpitation YESNO
  • Tachycardia YESNO
  • Arrythmia YESNO
  • Chest distress YESNO
  • Heartache
    • Angina pectoris YESNO
• Breathing difficulty YESNO
• Cough YESNO
• Phgelm YESNO

• Digestive problems

  • Regurgitation YESNO
  • Heartburn YESNO
  • Bloating YESNO
  • Fullness YESNO
  • Nausea YESNO
  • Vomitting YESNO

• Liver problems

  • Jaundice YESNO
  • Biliary colic YESNO

• Irregularities of stool

  • Constipation YESNO
  • Diarrhea YESNO
  • Bloody stool YESNO

• Urinary problems

  • Too frequent YESNO
  • Burning sensation YESNO
  • Bloody urine YESNO
  • Reoccuring UTI YESNO
  • Uncontrollable bladder YESNO

• Vascular problems

  • Thrombosis YESNO
  • Phlebitis YESNO
  • Varicose vein YESNO
  • Leg swelling YESNO
  • Heaviness of legs YESNO
  • Calf cramping YESNO

• Gynecological problems

  • Menstrual cramping YESNO
  • Heavy bleeding YESNO
  • Cycle abnormalities YESNO
  • Are you currently using contraceptive pills? YESNO
  • Are you currently using contraceptive patches? YESNO
• Sexually transmitted diseases YESNO
• Sexual dysfunction YESNO

• Allergies

  • Hayfever YESNO
  • Others YESNO
• Asthma YESNO
• Numbness of legs and arms YESNO
• Muscle fatique YESNO
• Tremors YESNO
• Abnormalities in taste and smell YESNO

• YES NO
• b) Do you smoke? YESNO
  • If yes, how much?

• YES NO
• c) Do you drink? YESNO
  • If yes, how much?
  • How often?

• YES NO
• d) Are you currently on medication?? YESNO
  • Any particular blood-thinners? YESNO
  • Others? Dosage?

• YES NO
• e) Do you take illicit drugs? YESNO
  • If yes, which type?

• YES NO
• f) Do you play sport? YESNO
  • If yes, what and how often a week?

• YES NO
• g) Are you exposed to any of the following climate factors at work or at home?
  • Breeze/Wind? YESNO
  • Humidity? YESNO
  • Heat? YESNO
  • Cold? YESNO

• YES NO
• h) Are you often
  • Angry / short-tempered YESNO
  • Restless / anxious YESNO
  • Lively / optimistic YESNO
  • Sorrowful YESNO
  • Sad / depressed YESNO
  • Scared / fearful YESNO
  • Forgetful YESNO

• YES NO
• i) Do you often fell overly
  • Hot YESNO
  • Cold YESNO

• YES NO
• k) Do you prefer
  • Heat YESNO
  • Cold YESNO

3. Personal history

• a)? Disease
• Do you suffer from
  • YES NO
  • Hypertension YESNO
  • Hypotension YESNO
  • Diabetes YESNO
  • Infectious diseases (HIV, Hepatitis etc.) YESNO
  • Tuberculosis YESNO
  • Osteoporosis YESNO
  • Epilepsy YESNO

• YES NO
• b) Unique circumstances
  • Are you carrying an artificial heart valve? YESNO
  • Women - Are you currently pregnant? YESNO

c) Please state any surgery, serious sickness or accident you have sustained in the past

• When?
• What?
• Where? (Hospital duration)

4. Family history: please state if any of the following diseases have occured in your family

• YES NO
• Cardiovascular disease (Hypertension, Infarction etc.) YESNO
• Stroke YESNO
• Allergies (Asthma, Hayfever, food allergies etc.) YESNO
• Cancer YESNO
• Diabetes YESNO
• Obesity YESNO
• Neurological diseases (Multiple sclerosis etc.) YESNO
• Rheumatism YESNO
• Epilepsy YESNO
• Psychiatric disorders (Depression, schizophrenia etc.) YESNO
• Others YESNO