Enter your gender here
Enter your main complaints
Diseases that run in the family (asthma, eczema, allergies, cancer, diabetes, rheumatism, etc.,). Mother, father, grandparents (father's and mother's side), children and siblings
Operations and hospitalizations gone through (include year)
Please list here what medications you take, for how long and how much (antibiotics, paracetamol, corticosteroids, birth control pill, creams, etc.).
Please list here which dietary supplements you use, for how long and how much?
Vaccinations as a child and later vaccines (related to travel, flu prevention, please include years, etc.)
Particulars before/during/after your own birth (e.g., mother's medication use during pregnancy, emotional events, childbirth initiation, pain management, etc.):
Do you maintain a diet and if so what diet(s)
How much do you drink per day, of water or (herbal) tea
Smoking, alcohol, weed, or other drug use, per day or per week:
Do you have certain Allergies/ hypersensitivities (food, supplements and medications?):
We recommend that you always inform your doctor about your treatment plan.
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Here you can upload your files (think blood results etc). PDF only
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