How to use this questionnaire:

If you can detail the information would be very well, otherwise just type an "Y" where appropriate or leave blank.
Where needed or asked for, please be more specific and precise as well. Thank you.
After the completion of the data, press the SUBMIT button at the beginning or end of the document to send to ben@uniserve.com.

General Data

Name:           
Birth date:     
Sex:            Male, Female.
Address:        
City:           
Prov/State:     
Zip/Post. Code: 
Country:        

Phone:          
Fax:            
E-mail:         

Part A

 Premature ageing:          
 Chronic illness (see also specific illness in part B):
 Excessive physical and mental exertion:       
 Conflicts:
 Inappropriate or inadequate physical activity:
 Convalescence:             

Family Stress:
 Large family  		
 Increased financial responsibilities  		
 Marriage conflicts  		
 Conflicts with children/parents/siblings  		
 Loss of loved ones 

Stress at Work:
 Increased job responsibility  		
 Poor motivation  		
 Routine, boring work  		
 Frustration  		
 Rivalry at work 

Stress Increase due to major changes in life:
 Loss of job  		
 Financial loss  		
 Death in family  		
 Retirement  		
 Social isolation  		
 Menopause 
 Andropause

Everyday stresses:  		
 Pressures of living in large cities  		
 Social/Cultural pressures 

Nutritional Stress:
 Poor dietary habits  		
 Intolerance/allergies to food additives/preservatives (See part B)  		
 High junk food consumption 

Harmful habits:
 Smoking  		
 Excessive alcohol consumption 
 Excessive use of pain medications  		
 Gastrointestinal disorders due to poor diet   

PART B

Cardiovascular problems: 
 myocardial infarction. When? 
 bypass surgery. When? 
 angina pectoris 
 tachycardia 
 hypertension (high blood pressure)   

Circulatory: 
 poor arterial circulation 
 poor venous circulation 
 leg cramps 
 tired legs 
 swollen ankles 
 varicose veins 
 falling asleep of the hands and legs 
 tingling sensation in arms and legs 
 leg ulcers   

Gastro-intestinal problems: 
 digestion problems 
 acid indigestion 
 bloating 
 stomach or duodenal ulcer. When? 
 loss of appetite 
 rapid weight gain 
 rapid weight loss 
 overweight problem 
 pancreas problems (e.g. pancreatitis, insufficiency)
 candida			
 yeast infection (female)  
 Acne, (Red nose - use latin name), Candida Internal 
 hepatitis 
 gall bladder problems 
 gall stones 
 icterus (jaundice) 
 recurring diarrhea   

Pulmonary system: 
 tuberculosis 
 Asthma 
 chronic bronchitis 
 chronic cough 
 emphysema   

Upper respiratory tract: 
 chronic sinusitis 
 allergic sinus problem 
 chronic allergic rhinitis 
 sinus headaches 
 chronic nose bleeds 
 chronic colds   

Neurological system: 
 nervous disturbances (please name)
 depression 
 loss of memory 
 lack of concentration 
 decreased sexual potency 
 headaches 
 sleep disturbances 
 dizziness 
 chronic migraine 
 reduced vitality 
 psychiatric disturbances   

Endocrinological system: 
 diabetes mellitus 
 thyroid dysfunction (e.g. overactive, underactive)
 adrenal gland dysfunction 
 female menopause (hot flashes, etc.) 
 andropause (male menopause), decreased sexual potency 
  Others (please list)
  
Rheumatic screen: 
 soft tissue rheumatism 
 articular rheumatism 
 joint pain 
 back pain 
 rheumatoid arthritis 
 Others (please list)

Fibromalgia?
 When?

Allergy history: 
Have you ever had an allergic reaction to any of the following items: 
 food, esp. eggs			
 vaccinations			
 medications			
 do you suffer from hay fever   
 allergic asthma			
  Others (please list)

Operations:
 What? When?

General Information: 
 Previous medications
 Current medications
 Anticoagulators? Since when? Why?

 When was your last vaccination
 When were you last ill? Diagnosis?

 Do you smoke? (cigarettes, cigars, pipe) How many (daily)
 Alcohol consumption (wine, beer, hard liquor) How much (daily)

Have you ever had Hydrazine Sulfate therapy before?
 When, Where, Why