Patient questionnaire

Please fill out the on-line form below, or download it, fill in and send it by e-mail/fax. Our experts, Dr.Ph. Ulrike Okon, Gotha, Germany and Dr. Belčić Tamara, Niš, Serbia, will it for free evaluate and in few days we will send you back the review of your condition and useful advices for improvement.

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

Data on practice:

Name of the practice

Name of the physician

Street and number

Zip code, town

Telephone/fax

Details on patient:

Name and family name

Date of birth

Street and number

Zip code, town

Telephone/fax

Email

Health insurance

Basic questionnaire

Weight

Height

Eyes color

Hair color and density

Online circles

Physique limbs

Symmetry of the abdomen

Stomach ache

Palpation measurement of lactic acid

Do you suffer from any chronic illness, and since when?

Do you smoke ?

How much per a day?

Do you take painkillers?

Do you tolerate heat ?

Do you have dental amalgam fillings or palladium?

When you remove them?

Did you do the blood test for heavy metals?

Have you been vaccinated and what of (If you have a vaccination certificate, please attach a copy)

How much load you can handle?

Do you have pain when moving? (Please answer honestly)

Good raw food intolerance?

Do you have problems with bloating when consuming raw foods?

Do you have any scars?

Where on the body?

What medications and when do you use? (Please answer honestly)

(Attention: drug may reduce the dose or interrupt input, only after approval of your doctor)

How often do you have bowel?

What is the consistency of the bowel?

How many times have you been to the doctor, the clinic, homeopath? Number:

What treatments have you had so far? (Please answer honestly)

How often do you intake fluid? (Please answer honestly)

What food do you eat? (Just answer)
Sugar  Yes No

Quantity/ how often

Dairy products  Yes No

Quantity/ how often

Products made of white flour  Yes No

Quantity/ how often

Eggs  Yes No

Quantity/ how often

Walnuts  Yes No

Quantity/ how often

Sweets  Yes No

Quantity/ how often

Cakes  Yes No

Quantity/ how often

From disease suffer in your family?

Father

Mother

Grandmother

Grandfather

Brother

Sister

How many hours a day do you sleep?

Do you feel rested and fresh after sleep?

How high do you assess your stress and emotional burden?

Without food you cannot be without?

What are your biggest difficulty burden?

Are you ready to change your diet with our help?

Do you have an autoimmune disorder of the thyroid gland work?

2-part- Autoimmune Disease- reduced / increased thyroid gland function

1. Sex

2. (If you're a woman) Do you have irregular periods, or have poor / heavy menstrual period?

3. (If you're a woman) Are you pregnant or have been in previous years?

4. (If you're a woman) Do you have a problem getting pregnant or have had a miscarriage?

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

6. Do you have hair loss or hair or eyebrows?

7. Did you have muscle pain or weakness of the muscles of the arms and legs?

8. Have you had any of the following signs?
 Dry skin Swelling of the face Brittle hair Brittle nails No

9. Do you rapidly gain weight and it is not related to diet and exercise, or you cannot lose weight

10. Do you quickly lose weight, and if you have a normal or increased appetite?

11. Do you feel tired and fatigued?

12. Do you believe that your fatigue is consequences of sleep deprivation?

13. Do you have problems with concentration, or memory or "blur brain"?

14. Do you feel depressed, anxious or indisposed?

15. Are you often nervous, irritable?

16. Are you hyperactive?

17. Are to you often indisposed?

18. Do you mind the heat?

19. Is your sexual libido reduced, extinguished?

20. Do you have a slow heartbeat, palpitations, or low blood pressure?

21. Do you feel fine in the heat, or have cold hands and feet?

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

23. Do you have frequent bowels, 3-4 times a day?

24. Do you have any of the following symptoms?
Horse voice Sensitivity of neck/Failure tie Chains Scarves/Nothing stated 

25. Do you have any of the following symptoms?
Involuntary movements Hand tremor Intense sweating The damp, clammy skin Nothing 

26. Do you have a personal or family history of thyroid disorders and autoimmune diseases?

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

28. Do you have swollen anterior part of the neck or goiter?

29. Have you had any of the following treatments?
Treatment with lithium Amiodarone therapy Drugs based on iodine Medical tests including iodine None of the above 

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

31. Do you have a high level of cholesterol in the blood, cholesterol that does not react on the drug?

32. Last value hormones - in the blood:

Date

TSH (mlU/l) :

FT3 (pmol/l) :

FT4 (pmol/l) :

I hereby certify that my health condition will be evaluated by Naturheilpraxis Ulrike Okon, Gotha, Germany, authorized therapist Kasfero.

I hereby certify that company Kasfero will send me the evaluation of my health condition made by aforementioned therapists and useful advices for improvement.
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