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.

First name:
Working as:

Oral symptoms
Bleeding gumsstrongfairly stronga littlenothing
Tooth grindingstrongfairly stronga littlenothing
Burning tonguestrongfairly stronga littlenothing
Dry mouthstrongfairly stronga littlenothing
Metallic taste in the mouthstrongfairly stronga littlenothing

Contact Excemayes no
Washing powder allergystrongfairly stronga littlenothing
Allergy to cosmeticsstrongfairly stronga littlenothing
Other allergiesyes no
Food allergiesstrongfairly stronga littlenothing
Excema (Neurodermatitis)strongfairly stronga littlenothing
Skin rashstrongfairly stronga littlenothing
Hay Feverstrongfairly stronga littlenothing

Asthma / Chronic Bronchitis
Allergy test of the blood / Positiveyes no
Allergy test on the skin / Positiveyes no

Chronic or frequent infections or inflamed irritations of...
The nosestrongfairly stronga littlenothing
Sinusesstrongfairly stronga littlenothing
Throat areastrongfairly stronga littlenothing
Feverish infectionsstrongfairly stronga littlenothing
Herpes simplexstrongfairly stronga littlenothing
Heartburnstrongfairly stronga littlenothing

Do you suffer from...
Chronic headachesstrongfairly stronga littlenothing
Migrainestrongfairly stronga littlenothing
Location of pain: left/right, both sides, back of head, forehead
With nauseastrongfairly stronga littlenothing
Worse in lightstrongfairly stronga littlenothing

Do you suffer from...
Lack of drivestrongfairly stronga littlenothing
Tirednessstrongfairly stronga littlenothing
Lack of concentrationstrongfairly stronga littlenothing
Depressionstrongfairly stronga littlenothing
Extreme nervousnessstrongfairly stronga littlenothing

Do you suffer from...
Fearstrongfairly stronga littlenothing
Sleeplessnessstrongfairly stronga littlenothing
Problems getting to sleepstrongfairly stronga littlenothing
Problems sleeping through the nightstrongfairly stronga littlenothing
Shakingstrongfairly stronga littlenothing
Visual problemsstrongfairly stronga littlenothing
Tinnitus (ringing in the ears)yes no

Heart / ciculation
Irregular heartbeatstrongfairly stronga littlenothing
Heart racingstrongfairly stronga littlenothing
Abnormal sweatingstrongfairly stronga littlenothing

Dizzinessstrongfairly stronga littlenothing
Low blood pressurestrongfairly stronga littlenothing
High blood pressurestrongfairly stronga littlenothing

Backachestrongfairly stronga littlenothing
Cervical vertebrae areastrongfairly stronga littlenothing
Thoracic areastrongfairly stronga littlenothing
Lumbar areastrongfairly stronga littlenothing

Rheumatismstrongfairly stronga littlenothing
Problems in the jointsstrongfairly stronga littlenothing

Incontinence / bedwetting
Incontinence / bedwettingstrongfairly stronga littlenothing
Frequent urinationstrongfairly stronga littlenothing
Need to urinate in the nightstrongfairly stronga littlenothing
Swollen legs at nightstrongfairly stronga littlenothing
Hair lossstrongfairly stronga littlenothing

Digestion problems
Constipationstrongfairly stronga littlenothing
Flatulencestrongfairly stronga littlenothing
Diarrhoeastrongfairly stronga littlenothing
Bowel movementdailyfrequently in a dayevery 2 days3 days or more

Eye infections
Dry eyesstrongfairly stronga littlenothing

Do you suffer from other illnesses or complaints?
Varicose veinsyes no
Diabetesyes no
Thyroid complaintsyes no
Pancreatic problemsyes no
Results of laboratory testsyes no

Are there other illnesses or complaints?
If yes:

For women
Menstrual cycleregularirregular
Premenstrual painyes no
Pain during menstruationyes no

Tumorous growthsyes no
Affecting which organ?
Has the tumor been operated on?yes no
Chemotherapyyes no
Radiotherapyyes no
Hormonal therapyyes no
Have you suffered a relapse?yes no

Previous illnesses and operations
If existing:

Childhood illnesses
Chickenpoxyes no
Measlesyes no
Rubellayes no
Mumpsyes no
Whooping coughyes no

Other illnesses
If existing:

Fungal infections
Bowel infectionyes no
Vaginal infectionyes no
Nail fungal infectionyes no
Frequent antibiotic useyes no

Serious infections
Jaundiceyes no
Influenzayes no
Tubercolosisyes no
Intestinal infectionyes no
Glandular Feveryes no
Other infectionsyes no

Bad reaction to vaccinationyes no
Oversea travel vaccinationyes no
Tubercolosis vaccinationyes no

Occupational hazards
Chemical hazards - currentyes no
Chemical hazards - in the pastyes no
Heavy metals etc.yes no
Traffic stress during workyes 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

Petsyes no
Dogyes no
Catyes no
Guinea Pigyes no
Fishyes no
Rabbityes no
Horseyes no
Birdyes no
Other animalsyes no

Teeth, Jaw and root treatment
How many amalgam fillings?
How many replacement amalgam fillings?
How many during the last 10 years?
DMPSyes no
Zincyes no
Seleniumyes no
Homeopathic remedy
Other improvements following removal of amalgamyes no
If yes, what?
Replacement with gold / silver coloured materialyes no
Bridgesyes no
Crownsyes no
Inlaysyes no
Part prosthesesyes no
Other tooth replacements
Root filled, dead or other abnormal teethyes no
Other abnormalities in the jaw regionyes no
Abnormal top jawyes no
Abnormal bottom jawyes no
Allergy tests for dental materialsyes no
Blood testyes no
Skin testyes no
DMPS testyes no
LTT, Melisa testyes no

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

Fast foodyes no
Mixed dietyes no
Vegetarianyes no
Uncooked vegetarian foodyes no