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Name: *

Date of Birth: *

Address: *

Gender: *

Male
Female

Email: *

Telephone: *

Skype username: *

Main complaint (description, medical diagnose, when was diagnosed, what medication and dosage, when did medication start) *

Other complaints (data on same format as above) *

Surgeries you had (when, what condition)? *

What does improve your condition (i.e. sunshine, swimming in the sea, massage, walking, lying down, darkness etc.)? *

What does aggravate your condition (i.e. certain foods and drinks, humidity, noise, high temperatures, certain fabrics etc.)? *

How many antibiotic courses have you had over last 5 years? *

Current/past allergies (to food, drinks, pollutants, medication, anesthetics, paint, fragrances, hay-fever etc.) *

Medical history: please list CRONOLOGICALLY all your medical conditions since birth and treatments received (start with earliest years) *

Can you point to a certain moment since you haven’t been well (i.e. swimming in a river, visiting parents, relationship issues, immigration, head injury, holiday abroad, missing promotion etc.)? *

Frequency of colds/flu (very often, often, seldom, rare) and how quickly you recover

How many hours do you sleep, between what interval of time?

Do you wake up refreshed or find it difficult to get up?

How is your energy level during the day?

How varied is your diet?

Are most of your meals home or ready – made meals?

Would you say you are aware and careful of what you eat in terms of quality and diversity?

Are you vegetarian/vegan? If so, since when?

Do you supplement? If so, list your supplements.

Do you have any eating disorder?

How do you feel before/after meals?

How do you feel if you skip a meal?

How is your current appetite & thirst?

Are you anemic?

Do you have low or high blood pressure and take medication for it?

Do you have high cholesterol and take medication for it?

How much do you rely on stimulants to get you through the day(coffee, energy drinks, alcohol etc.)?

Level of exercise & fitness? Do you regularly practice a sport(s)?

How frequently do you walk (daily, weekends only) and for how long?

How regular are your bowel movements?

Do you tend to suffer with diarrhea, constipation, vomiting, abdominal cramps, flatulence, bloating, reflux or other sort of digestive issues?

Are you on any sort of diet? What’s the reason?

Do you experience headaches/migraines? How often, what time of the day?

Do you sweat abundantly, medium or not at all? If yes, which part of the body, mostly?

Do you have frequent/chronic skin conditions?

What would you say is the level of your stress (past, current)?

Did you go through adverse childhood events? (abuse, divorce, death, imprisonment of parent(s), separation etc.)

Have you recently been going through traumatic events? (divorce, death of a dear one, break-ups, unemployment, school/work pressure etc.)

Do you believe you have mental health issues? Have any been diagnosed and medicated?

Do you experience much tension, depression, anxiety, panic attacks, mood swings, feeling low? If so, how frequently?

Do you find it easy or very difficult to open – up, speak of your troubles, ask for help?

What are your biggest fears and phobias (death, sickness, loss of independence, abandonment, being used, speaking in public, fear of rats, heights, crowds, narrow spaces etc.)

Do you experience strong feelings of guilt or shame?

On a scale of 1 (very low) to 5 (very high), how do you rate your confidence?

Please list medical conditions of your close family members; if they passed away due to a certain medical condition, please state (also the age they had passed away) *

Mother, Father, Siblings, Grandmother (mother side), Grandfather (mother side), Grandmother (father side), Grandfather (father side), Other members (if you deem information as important)