Health Questionnaire
Please,
1) click on the page and highlight (press Ctrl A) then
2) copy (Ctrl C) the following
Health Questionnaire ,
3) then click on healthrecovered@ntlworld.com and
4) paste (Ctrl V) it in the email box.
5) Answer the questions and
6) click send.
You will be contacted shortly after your email has been received.
PRIVATE AND CONFIDENTIAL
HEALTH QUESTIONNAIRE
- Name* -
- E-mail* -
- Date of Birth - dd, mm, year -
- Time of Birth - h, min. -
- Place of Birth - Town, Country -
- Place of Residence - Town, Country -
- Sex - Male, Female
- Ethnic origin - White, Asian, African, Other
1. Name of your current illness/es;
- When (year, month) did they begin?
- Explain all of your symptoms and where you have pain or discomfort.
2. Name all of the illnesses you have suffered from; start from your childhood - until now. -
3. What is your blood pressure, pulse? -
4. What is your cholesterol level? -
5. Which of the following refers to you? - Yes or No
- Intolerance to light -
- Bruise easily -
- Skin heals quickly from sores -
- Rheumocardit -
- Cardiovascular insufficiency -
- Depression -
- Stress -
- Headaches/Migraine
- Fatigue
- Backache
- PMS
- Hemorrhoids
- Constipation
- Diarrhea
- Intestinal cramps
- Abdominal bloated feeling
- Other:
6. Do you have Swelling? - Yes/ No
- If you have Swelling, Where? -
Feet -
Legs -
Under the eyes -
Whole body -
7. Do you smoke? - Yes/ No
If Yes, Select -
Cigarettes
Cannabis
8. Do you use Alcohol? - Yes/ No/ Occasionally
- If Yes, name it (concentrate or weak):
9. Are you dependent on antidepressants or other drugs? - Yes/ No
10. Have you had any
- weight loss
- weight gain
11. Do you treat your illness? - Yes/ No
- If Yes, select from below:
Counselling
Remedial Massage
Yoga
Physiotherapy
Gym
Stretching
Walks
Diet
Sunbathing
12. Name the Medicines you use any to treat your illness (if you use):
13. Do you eat RAW LIFE FOOD? - Yes/ No/ Occasionally/ Little
Select:
Fresh raw Tomatoes
Fresh raw Peppers
Fresh raw Onions
Lettuce
Cucumber
Fresh raw Fruit
Unheated Oil
Unsalted Butter
Honey
Brown Sugar
Wholemeal grains
Feta Cheese
Plain Living Yoghurt
Filtered Water
Herb Tea
Fresh squeezed Fruit or Vegetable Juice
14. Do you eat PROCESSED FOOD - Yes/No/Little
Select:
Cooked vegetables
Meat
Fish
Poultry
Tinned foods
Take away meals
Fried/cooked oil
Margarine
Tinned fruit
White sugar
Sweet products
Sweets
White bread
Biscuits
Cheese
Carbonated drinks
Alcohol
Juice concentrate
Dairy products
Sweet yoghurt
Milk
Ice cream
Milk drinks
Black tea
Coffee
Cola drinks
Carbonated drinks
Energy drinks
15. Determine your pain level
- between 0 and 100%
16. Determine your energy level
- between 0 and 100%
17. How did you find my website?
- Internet search
- Got link from a friend
- Found link on another site
- Saw your ad in a newspaper
- A patient of yours recommended your treatment to me
*Fields marked with an asterisk are required fields.
* * * * * * * * * * * * * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * * * * * * * * *
ISKRA HEALTH SYSTEM
THE THERAPY THAT RECOVERES THE WHOLE BODY
