Confidential medical history questionnaire Full Name Occupation Phone Email Address Your GP's name and address Do You Have or Have You Had Any of the Following ?
Anaemia/Blood clotting disorders
Heart condition/Heart attack/Angina
Asthma or other chest problems
Bad reaction to local anaesthetic
Infectious diseases (HIV,etc...)
Treatment that required you to stay in hospital
Are you taking any medications?
Are you taking the contraceptive pill ?
Are you trying to conceive ?
Health-related questions Reason for consultation
Acute medical complaints: where and since when?
Acute dental complaints: where and since when?
Do you have any symtoms related to heavy metals of infected teeth?
Do you consume sugar and sugary drinks? If so, which ones and how often / how much?
Do you consume dairy products? If so, which ones and how often / how much?
Do you eat white bread and other white cereal/grain products?
Do you eat meat or sausages? If so, which ones and how much?
Do you eat fish? If so, which ones and how often / how much?
Do you smoke? If so, how often / how much?
Do you consume alcohol? If so, which products and how often / how many units per week?
How many hours a day do you spend with digital media (TV, computer, smartphone, tablet) on average?
Do you use a DECT telephone (cordless) at home or at your place of work?
Do you make phone calls with your smartphone placed next to your ear? If so, how many minutes a day?
Do you have Wi-Fi at home and do you turn it off at night?
How far is the next cell tower from where you sleep, and since when?
Do you have Wi-Fi reception from surrounding buildings or apartments?
Do you exercise and if so, which types of exercise and how often / how much?
How many hours do you sleep on average each night? What percentage of your waking hours would you categorise as being stressful? Clinical documents Please upload any x-rays or blood test report you have recently had Signature I hereby confirm with my signature that all the information provided here is truthful and that it is useful to treat and advise me for a better health achievement I hereby confirm with my signature that I agree with the data collection (photos,x-rays,videos,blood samples) for diagnostic and scientific purposes. Submit