Intake Form

if you prefer filling in the form on paper, you can download and print the intake form here.

    All fields in this form are required

    Patient information

    First Name

    Last Name

    Gender
    MaleFemale

    Marital status
    UnmarriedMarried

    Birth date (dd-mm-yyyy)

    Length in CM

    Weight in Kilos

    Home phone

    Cell phone

    Address [Street, City, Zipcode]

    Occupation

    IMPORTANT: People who have received organ transplants, including those who have pig valves in their heart and people who have artificial arteries, veins, shunts, or artificial urethras cannot be treated with this system.
    This therapy regenerates and strengthens your immune system to the extent, that foreign organs may be rejected.
    Other forms of prosthetics do not seem to present any problem.

    Main Problem/Complaints

    Symptoms [All, physical and mental]

    When exactly did the complaints start?

    When are the complaints the most severe?

    When are the complaints the least severe?

    Medical History and General Health

    Which mayor diseases did you suffer in the past? [history of disease/illness]

    Did you undergo surgery?
    YesNo

    Do you have (surgical) scars?
    YesNo

    Have you ever had a whiplash accident? [car crash, bike accidents, sports, etc.]
    YesNo

    Do you follow a diet? [vegetarian, fast-food, intolerances, etc.]
    YesNo

    How are your excrements? [frequent, consistent, color, smell]

    Do you practice any sport?
    YesNo

    Do you sleep well? Do you feel well rested after a good night's sleep?
    YesNo

    Do you have a clockradio beside your bed?
    YesNo

    Medication

    Painkillers
    YesNo

    Antibiotics
    YesNo

    Anti-depressants
    YesNo

    Cortison/Prednisone
    YesNo

    Beta-blockers
    YesNo

    Laxatives
    YesNo

    Gastric juice breakers
    YesNo

    Malaria
    YesNo

    Other medication?

    Vaccinations

    Dipheteria
    YesNoUnknown

    Pertusis
    YesNoUnknown

    Cholera
    YesNoUnknown

    Tetanus
    YesNoUnknown

    Poliomyelitis
    YesNoUnknown

    Mumps
    YesNoUnknown

    Morbillium (measles)
    YesNoUnknown

    Rubella
    YesNoUnknown

    Yellow Fever
    YesNoUnknown

    Hepatitis
    YesNoUnknown

    Meningococcen
    YesNoUnknown

    Varicellen
    YesNoUnknown

    Haemophilus type B
    YesNoUnknown

    Other vaccinations?

    Referred by?