Patient questionnaire

Please fill out the online form below. By filling out this form, we guarantee that you are not obliged to any kind of purchase or anything else if you do not wish so freely. Our experts will evaluate your data free of charge and in few days we will send you back the review of your condition and useful advice for improvement.

In case you do not know the answer to any of the questions, skip the question. Thank you.

Patient details:

1. Name and last name of the patient

2. Date of birth

3. Street and number

4. Zip code, town, state

5. Telephone/fax no.

6. Email

7. Name of your medical office

8. Office - zip number, place

9. Ordinacija - telefon/fax

Basic questionnaire

10. Weight

11. Height

12. Eye color

13. Hair color and density

14. Do you have eyebags/dark circles under your eyes?

15. Musculature of the limbs

16. Symmetry of the abdomen

17. Stomach pains

18. Do you have allergies to certain medications or substances, food etc.? And since when?

19. From what are you suffering from, how long and how often(eg. headache, joint pain)? If you have a determined diagnosis, provide it here:

20. Do you smoke?

21. How many per day?

22. Do you take painkillers?

23. Which painkillers do you use and since when? (please specify the names)

24. Do you have dental fillings made from amalgam or palladium?

25. When did you remove them?

26. Have you done blood tests to check for heavy metals?

27. Have you been vaccinated and what for (if you have a vaccination certificate, please attach a copy)

28. How much load you can handle? Simply describe your current physical and psychological state

29. Do you experience pain while moving? Bones, muscles? (please answer honestly)

30. Do you tolerate raw foods?

31. Do you have problems with bloating while consuming raw foods?

32. Do you have any scars?

33. Where on the body?

34. What medications do you use, and since when? This does not refer to painkillers, but all other medication, if you use them. (please, answer honestly) br />

(Attention: the dosage of your medication or complete cancellation of intake can be done only after the approval of your physician)

35. How often do you have bowel movements?

36. What is the consistency?

37. How many times have you been to the doctor, or a clinic, or a homeopath about your current condition? Number:

38. What treatments have you had so far? (please answer honestly)

39. What is your daily water intake? (please answer honestly)

What food do you eat? (simply answer)
40. Sugar YesNo

41. Quantity/ how often

42. Dairy products YesNo

43. Quantity/ how often

44. Products made from white flour YesNo

45. Quantity/ how often

46. Eggs YesNo

47. Quantity/ how often

48. Walnuts YesNo

49. Quantity/ how often

50. Sweets YesNo

51. Quantity/ how often

52. Cakes YesNo

53. Quantity/ how often

54. What diseases and conditions are known to run in your family?

Father

Mother

55. How many hours a day do you sleep?

56. Do you feel rested and fresh after sleep?

57. How high do you assess your stress and emotional burden? (exclusively psychological burden)

58. Which food you cannot be without?

59. What represents your biggest burden? (job, family, obligations etc.)

60. Are you ready to change your diet with our help?

61. Do you have an autoimmune disorder of the thyroid gland?

62. Are you diagnosed with diffuse goiter?

63. Are you diagnosed with diffuse goiter I, II or III?

64. Are you diagnosed with uninodular goiter (one nodule)?

65. Are you diagnosed with polynodular goiter (two or more nodules)?

66. Are you diagnosed with Graves' disease?

67. Are you diagnosed with dysthyroid ophtalmopathy (Graves' orbitopathy?

68. Are you diagnosed with Hashimoto's thyroiditis?

69. Are you diagnosed with hypothyroidism?

70. Are you diagnosed with any other type of thyroid gland dysfunction? Or are you diagnosed with any other type of disroder/disease

71. Do you have irregular periods?

72. Do you have light or heavy flow periods?

73. Are you currently pregnant?

74. (If you're a woman) Do you have problems getting pregnant?

75. (If you are a man) Do you have fertility or impotence problems?

76. Do you have problems with hair loss(head, eyebrows etc.)?

77. Do you have muscle pains or weakness of the muscles in the limbs?

78. Do you have any of the following signs?
Dry skinSwelling of the faceBrittle hairBrittle nailsNo

79. Do you rapidly gain weight even though you take care of your diet?

80. Do you quickly lose weight, ecen though you have normal or increased appetite?

81. Do you constantly feel tired and fatigued?

82. Do you believe that your fatigue is a consequence of sleep deprivation?

83. Do you have problems with your concentration, or memory, or have a sort of "brain fog"?

84. Do you often feel depressed, anxious or indisposed?

85. Are you often nervous, irritable, with no apparent reason?

86. Are you hyperactive?

87. Do you often feel sad? (don't feel like smiling and laughing)

88. Do you have problems with heat - meaning the usual temperature?

89. Is your sexual libido reduced, or extinguished?

90. Do you have a slow heartbeat, or heart palpitations?

91. Do you feel as if your hands and feet are constantly cold?

92. Do you have constipation or constipation that does not respond to therapy?

93. Have you ever tried yoga or fast walking?
yogafast walking

94. Do you have any of the following symptoms?
hoarse voicesensitivity of neckproblems with wearing ties/necklaces/scarves

95. Do you have any of the following symptoms?
involuntary movementshand tremorsintense sweatingdamp, clammy skin

96. Do you have a family history of thyroid disorders and autoimmune diseases?

97. Do you have expressed, bulging eyeballs, exophthalmos?

98. Do you have a swollen front part of the neck or goiter?

99. Have you had any of the following treatments?
Lithium treatmentAmiodarone therapyDrugs based on iodineMedical tests including iodine

100. Did you have a radiograph of the neck, teeth, or have had radiation therapy of the head, neck or chest?

101. Do you have high levels of cholesterol in your blood?

102. Do you have cholesterol that doesn't react to therapy?

103. Your last known hormone values:

Date

TSH (mlU/l) :

FT3 (pmol/l) :

FT4 (pmol/l) :

TPO :

TRAK :

Bilirubin :

SHBG :

Progesterone :

Estrogen :

Iron-copper coefficient :

Iodine amount in urine :

I hereby certify that my health condition will be evaluated by the Office of natural medicine - Homeopathy - KASFERO NATURMEDIZIN®.

I hereby certify that company KASFERO NATURMEDIZIN®
will send me the evaluation of my health condition made by aforementioned therapist and useful advice for improvement. I confirm that I am informed about the fact that all written and spoken correspondence, as well as health advice and possible therapy are free and are under payment of the company KASFERO NATURMEDIZIN®.
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