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
Birth date (dd-mm-yyyy)
Length in CM
Weight in Kilos
Address [Street, City, Zipcode]
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.
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?
Do you have (surgical) scars?
Have you ever had a whiplash accident? [car crash, bike accidents, sports, etc.]
Do you follow a diet? [vegetarian, fast-food, intolerances, etc.]
How are your excrements? [frequent, consistent, color, smell]
Do you practice any sport?
Do you sleep well? Do you feel well rested after a good night's sleep?
Do you have a clockradio beside your bed?
Gastric juice breakers
Haemophilus type B