Entry questionnaire

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1 INTRODUCTION 2 PERSONAL DATA 3 PERSONAL HISTORY 4 PHARMACOLOGICAL HISTORY 5 FAMILY HISTORY 6 PREGNANCY, CHILDBIRTH, BREASTFEEDING 7 GYNAECOLOGICAL HISTORY (WOMEN ONLY) 8 DIET AND EATING HABITS 9 DIGESTION 10 SLEEP 11 STRESS 12 THYROID GLAND - hypofunction 13 THYROID GLAND - hyperfunction 14 MOVEMENT 15 TOXICITY 16 AIM OF COOPERATION 17 DOCUMENTS YOU WANT TO SHARE WITH US
Greetings!

We are very pleased that you are interested in using our consulting services. In order for us to properly prepare for your first consultation, please fill out the following form as carefully as possible. You do not need to be ashamed of any answers, however, if you find any of the questions uncomfortable, simply skip them.
We look forward to working with you!

Aleš and David
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Name *
Phone *
+420
Hledat
    Surname *
    Email *
    Date of Birth *
    Height/Weight *
    How did you hear about us?
    Recommendation
    Internet
    Other
    Address (billing) *
    Profession
    Sex
    Female
    Male
    Other
    On a scale of 1 to 10, indicate your usual energy level (10 = most energy):
    0 10
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    Some information about where you stand in terms of health ...

    What are your health problems? 
    When did you first notice these problems?
    What is your current blood pressure?
    Normal (up to120/80)
    Low
    Icreased (over 135/80)
    I don´t know
    Have you experienced any major life changes recently? What?
    How long have you been sick in the past year?
    Which doctors/therapists do you currently work with?
    Are you on long-term treatment for any other illnesses?
    Have you had a serious illness in the past? Surgery? What kind?
    Are you undergoing hormonal treatment, what kind  (contraception, hormone replacement therapy)?
    Do you have breathing problems?
    Yes
    No
    Do you suffer from any allergies (including food and drug allergies)?
    Are you currently on any medical or other diet (what kind, for how long)?
    Do you do drugs?
    No
    Regularly
    Recreationally
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    A little about the medicines and supplements you take ...

    What medications do you take, for what problems?
    Vitamins, minerals and other dietary supplements taken? Do you take them occasionally, permanently?
    What medications have you taken in the past that you no longer take? Why did you stop taking them?
    Do you use any herbal remedies or alternative healing methods?
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    Do any of your close blood relatives (parents, siblings, children, aunt/uncles) suffer from the diseases listed below? Who, please give age?

    Obesity
    High cholesterol
    High blood pressure
    Cardiovascular disease (myocardial infarction, stroke)
    Diabetes
    Disorders of thyroid function
    Autoimmune diseases
    Oncological diseases
    Mental illness
    Hereditary diseases
    Other diseases
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    Information about how your development took place before birth, birth and development after birth is very important ...

    How was your mother's pregnancy when she was pregnant with you? Was she on medication at the time? Was she going through a period of stress?
    Were you born naturally or by caesarean section?
    Natural childbirth
    Caesarean section
    I don´t know
    Were there any complications immediately after delivery?
    Have you been breastfed? For how long?
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    This section is for women only, other genders please skip ...

    What is your menstrual cycle like (how often, how long does it last)?
    Do you have irregular bleeding or spotting between periods?
    How do you feel during menstruation? Do you have pre-menstrual syndrome or painful menstruation?
    Do you have sore breasts, water retention or irritation during the second half of your cycle?
    Are you on hormonal contraceptives? What kind?
    Do you take any herbs to support hormonal balance? Which ones?
    Have you ever had a yeast infection or urinary tract infection? How many times, how often?
    Have you ever had trouble getting pregnant spontaneously?
    Did you have any complications during pregnancy, childbirth, or postpartum?
    Have you had a spontaneous abortion?
    Yes
    No
    I don´t know
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    Now a few questions about how you eat and drink...

    Are you currently on any special diet? What kind?
    How were you eating when your health problems began?
    What percentage of your diet is home cooking?
    Please check which daily meals do you usually eat?
    Breakfast
    Morning snack
    Lunch
    Afternoon snack
    Dinner
    The second dinner
    What does a typical breakfast, lunch, dinner or snack look like? What time do you eat these meals?
    What time is the last time you eat? Please indicate.
    Do you often feel hungry?
    Yes, often
    Occasionally
    No
    Do you sweeten?
    YES, I sweeten with sugar, syrups
    YES, I sweeten sometimes with sugar, sometimes with sweeteners
    NO, I don't sweeten
    YES, I sweeten with artificial sweeteners
    I sweeten rarely
    Do you feel tired after eating?
    Yes, often
    Occasionally
    No
    Are there any foods that don't make you feel good? List the foods and symptoms.
    Are there certain foods you often crave?
    Is there anything else we should know about your current or former diet, or your approach to food?
    How much fluid do you drink a day, what kind?
    Do you drink coffee, tea? In what quantity?
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    Now we're going to ask you how your digestive system works...

    Do you have digestive and digestive problems? 
    Heartburn
    Reflux
    Flatulence
    Diarrhoea
    Feelings of heaviness
    Burping/hissing
    Constipation
    Spasms
    Fatigue after eating
    How often do you suffer from these problems?
    Have you had food poisoning in the previous five years?
    What is your stool frequency?
    What is your usual stool colour (brown, yellow, green, grey, black, with blood)?
    What is your usual stool consistency? Select from the options
    Type 1
    Type 2
    Type 3
    Type 4
    Type 5
    Type 6
    Type 7
    Is there anything else we should know about your current or former diet, or your approach to food?
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    Tell us a little about your sleep...

    Do you regularly sleep 6 to 8 hours a day?
    Do you feel refreshed when you wake up?
    YES
    NO
    HOW WHEN
    Do you need a nap during the day?
    YES
    NO
    SOMETIMES
    Can you fall asleep without problems within 30 minutes of lying down?
    YES
    NO
    HOW WHEN
    Do you have a specific day or night schedule ( shift work, night duty, frequent time zone changes, frequent business trips, etc.) Please indicate.
    Do you wake up at night? How many times a night, at what time?
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    How are you in terms of stress?

    You're more of a character...
    Quiet
    Explosive
    Something between
    Do you have neurological difficulties?
    Insomnia
    Irritability
    Anxiety, depression
    Others
    Are you resilient to stress and how do you cope with stress?
    Are you sensitive to smells, odours, noise and harsh light?
    What's your mood in general? If you are ever anxious, depressed, aggressive, how often?
    When did you feel the best in your life? Why?
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    Please indicate the extent of your difficulties in the following fields

    Muscle weakness
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Frequent muscle cramps
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Greater need for sleep
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Joint and muscle pain
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Gaining weight
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Swelling of the hands and feet
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Constipation
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Difficulties with mathematics (counting)
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Slow thinking
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Depression, anxiety, mood changes
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Forgetfulness
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Fatigue, listlessness
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Feeling of cold hands, feet
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Dry skin, dry hair
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    A gruff voice
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Swollen eyes
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Decreased libido
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Coarse, frayed hair
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Growth of eyebrows
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Carpal tunnel syndrome (tendonitis)
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Irregular menstruation (only women)
    0 - no
    1 - mild
    2 - moderate
    3 - strong
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    Please indicate the extent of your difficulties in the following fields

    Heartbeat
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Accelerated heart rate
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Nervousness, irritability
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Inner tremor
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Shaking hands
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Insomnia
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Weight loss despite normal or increased food intake
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Loss of appetite
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Increased frequency of intestinal activity
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Sweating and heat intolerance
    0 - no
    1 - mild
    2 - moderate
    3 - strong
    Muscle fatigue or weakness
    0 - no
    1 - mild
    2 - moderate
    3 - strong
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    How are you doing in terms of physical activities... 

    Do you currently play any sports? How often and at what intensity?
    Did you play sports as a child, what kind, how intensively, for how long? Please indicate.
    Playing sports ...
    You enjoy
    You exercise out of necessity
    You can't force yourself
    Which sports are closer to you?
    Slow
    Fast
    None
    If I should increase my physical activity, I prefer the following activities ...
    Walking
    Nordic walking
    Jogging
    Swimming
    Aerobic
    Conditioning exercises
    Yoga
    Dancing
    Tennis
    Skating
    Other
    Do you come from a sporty family?
    ANO
    NE
    Additional information about your sport activities (competitive, professional activity, coaching, consulting).
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    A few questions about possible toxicities in your life...

    How often have you taken antibiotics in your life? When was the last time?
    Have you been vaccinated in the last 5 years, with what?
    Have you ever been exposed to chemicals or toxic materials?
    Have you ever had a tick?
    YES
    NO
    I don´t know
    Do you smoke, move around in smoky environments?
    Do you use a water filter for drinking water?
    YES
    NO
    Do you have amalgam fillings (conventional fillings)? How many?
    Please list the non-European countries you have visited in the previous 5 years.
    Is there mold in your apartment (or in the area where you stay frequently)?
    How often do you drink alcohol?
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    Please state specifically what is your goal of cooperation with our consultancy (what you would like to achieve).
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    Here you can attach important documents, test results, medical reports, etc.
    Přetáhněte soubory sem Procházet soubory

    By signing (by pressing the SUBMIT QUESTIONNAIRE button), I give my express consent to the use of all of my above data for the purpose of processing and storing it with the counsellor for as long as necessary and for as long as I visit the counselling centre. All of the above personal data will be used only for the purposes of the counselling centre and will not be disclosed to any other person or organisation. I am aware that I can withdraw this consent at any time.

    Souhlasy *

    I agree to the General Terms and Conditions and Privacy Policy

    Giving Informed Consent of the Client

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