Questionnaire, Symptoms, Illness

This questionnaire is basis for an initial therapeutical analysis. Its anonymised data will support our case studies. Your personal information will not be shared with others.

Name:	First name:	Birthday:
Street:	Zip/City/Country:	E-Mail:
Weight:	Height:	Working as:

Oral symptoms

Bleeding gums	strongfairly stronga littlenothing
Tooth grinding	strongfairly stronga littlenothing
Burning tongue	strongfairly stronga littlenothing
Dry mouth	strongfairly stronga littlenothing
Metallic taste in the mouth	strongfairly stronga littlenothing

Allergies

Contact Excema	yes no
Washing powder allergy	strongfairly stronga littlenothing
Allergy to cosmetics	strongfairly stronga littlenothing
Other allergies	yes no
Food allergies	strongfairly stronga littlenothing
Excema (Neurodermatitis)	strongfairly stronga littlenothing
Skin rash	strongfairly stronga littlenothing
Hay Fever	strongfairly stronga littlenothing

Asthma / Chronic Bronchitis

Allergy test of the blood / Positive	yes no
Allergy test on the skin / Positive	yes no

Chronic or frequent infections or inflamed irritations of...

The nose	strongfairly stronga littlenothing
Sinuses	strongfairly stronga littlenothing
Throat area	strongfairly stronga littlenothing
Feverish infections	strongfairly stronga littlenothing
Herpes simplex	strongfairly stronga littlenothing
Heartburn	strongfairly stronga littlenothing

Do you suffer from...

Chronic headaches	strongfairly stronga littlenothing
Migraine	strongfairly stronga littlenothing
Location of pain: left/right, both sides, back of head, forehead
With nausea	strongfairly stronga littlenothing
Worse in light	strongfairly stronga littlenothing

Do you suffer from...

Lack of drive	strongfairly stronga littlenothing
Tiredness	strongfairly stronga littlenothing
Lack of concentration	strongfairly stronga littlenothing
Depression	strongfairly stronga littlenothing
Extreme nervousness	strongfairly stronga littlenothing

Do you suffer from...

Fear	strongfairly stronga littlenothing
Sleeplessness	strongfairly stronga littlenothing
Problems getting to sleep	strongfairly stronga littlenothing
Problems sleeping through the night	strongfairly stronga littlenothing
Shaking	strongfairly stronga littlenothing
Visual problems	strongfairly stronga littlenothing
Tinnitus (ringing in the ears)	yes no

Heart / ciculation

Irregular heartbeat	strongfairly stronga littlenothing
Heart racing	strongfairly stronga littlenothing
Abnormal sweating	strongfairly stronga littlenothing

Dizziness

Dizziness	strongfairly stronga littlenothing
Low blood pressure	strongfairly stronga littlenothing
High blood pressure	strongfairly stronga littlenothing

Backache

Backache	strongfairly stronga littlenothing
Cervical vertebrae area	strongfairly stronga littlenothing
Thoracic area	strongfairly stronga littlenothing
Lumbar area	strongfairly stronga littlenothing

Rheumatism

Rheumatism	strongfairly stronga littlenothing
Problems in the joints	strongfairly stronga littlenothing

Incontinence / bedwetting

Incontinence / bedwetting	strongfairly stronga littlenothing
Frequent urination	strongfairly stronga littlenothing
Need to urinate in the night	strongfairly stronga littlenothing
Swollen legs at night	strongfairly stronga littlenothing
Hair loss	strongfairly stronga littlenothing

Digestion problems

Constipation	strongfairly stronga littlenothing
Flatulence	strongfairly stronga littlenothing
Diarrhoea	strongfairly stronga littlenothing
Bowel movement	dailyfrequently in a dayevery 2 days3 days or more

Eye infections

Dry eyes

strongfairly stronga littlenothing

Do you suffer from other illnesses or complaints?

Varicose veins	yes no
Diabetes	yes no
Thyroid complaints	yes no
Pancreatic problems	yes no
Results of laboratory tests	yes no

Are there other illnesses or complaints?

If yes:

For women

Menstrual cycle	regularirregular
Premenstrual pain	yes no
Pain during menstruation	yes no

Tumors

Tumorous growths	yes no
Affecting which organ?
Has the tumor been operated on?	yes no
Chemotherapy	yes no
Radiotherapy	yes no
Hormonal therapy	yes no
Have you suffered a relapse?	yes no

Previous illnesses and operations

If existing:

Childhood illnesses

Chickenpox	yes no
Measles	yes no
Rubella	yes no
Mumps	yes no
Whooping cough	yes no

Other illnesses

If existing:

Fungal infections

Bowel infection	yes no
Vaginal infection	yes no
Nail fungal infection	yes no
Frequent antibiotic use	yes no

Serious infections

Jaundice	yes no
Influenza	yes no
Tubercolosis	yes no
Intestinal infection	yes no
Glandular Fever	yes no
Other infections	yes no

Vaccinations

Bad reaction to vaccination	yes no
Oversea travel vaccination	yes no
Tubercolosis vaccination	yes no

Occupational hazards

Chemical hazards - current	yes no
Chemical hazards - in the past	yes no
Heavy metals etc.	yes no
Traffic stress during work	yes no
Other problems

Hazards in the home

Wood panelling (current domicile)	yes no
Wood panelling (previous domiciles)	yes no
Chipboard (current)	yes no
Chipboard (previous)	yes no
Mould (current)	yes no
Mould (previous)	yes no
Carpets (current)	yes no
Carpets (previous)	yes no
Industrial fumes (current)	yes no
Industrial fumes (previous)	yes no

Environmental hazards

Do you smoke?	yes no
If yes, how many cigarettes do you smoke per day?
Do others smoke in your home?	yes no
Are there smokers at your place of work?	yes no

Pets

Pets	yes no
Dog	yes no
Cat	yes no
Guinea Pig	yes no
Fish	yes no
Rabbit	yes no
Horse	yes no
Bird	yes no
Other animals	yes no

Teeth, Jaw and root treatment

How many amalgam fillings?
How many replacement amalgam fillings?
How many during the last 10 years?
DMPS	yes no
Zinc	yes no
Selenium	yes no
Homeopathic remedy
Other improvements following removal of amalgam	yes no
If yes, what?
Replacement with gold / silver coloured material	yes no
Bridges	yes no
Crowns	yes no
Inlays	yes no
Part prostheses	yes no
Other tooth replacements
Root filled, dead or other abnormal teeth	yes no
Other abnormalities in the jaw region	yes no
Abnormal top jaw	yes no
Abnormal bottom jaw	yes no
Allergy tests for dental materials	yes no
Blood test	yes no
Skin test	yes no
DMPS test	yes no
LTT, Melisa test	yes no

Medication

Are you taking regular medication?	yes no
If yes, which?
Previous long term medication	yes no
If yes, which?

Vitamins and trace elements

Are you taking vitamins?	yes no
If yes, which?
Are you taking trace elements?	yes no
If yes, which?

Diet

Fast food	yes no
Mixed diet	yes no
Vegetarian	yes no
Uncooked vegetarian food	yes no
Others