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Health Declaration
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First Name
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Last Name
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Date
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Gender
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Address
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Zip code
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Email
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Questions regarding your overall health
Are you currently healthy?
*
Yes
No
Do or did you suffer from one of the following conditions:
Heart diseases?
*
Yes
No
Serious hypertension?
*
Yes
No
Epilepsy?
*
Yes
No
Kidney failure?
*
Yes
No
Recently performed surgery?
*
Yes
No
Migraine?
*
Yes
No
Auto-immune diseases (such as rheumatism, MS, Crohn, diabetes, asthma), if so, which?
*
Yes
No
Auto-immune diseases
Other conditions
*
Yes
No
Other Conditions:
Do you currently use:
Medication for the heart
*
Yes
No
Medication name
Are you allergic to a certain substance? (food/environment etc.)
*
Yes
No
Allergies
Are you currently pregnant or do you wish to become pregnant?
*
Yes
No
Is there anything else your practitioner should know about?
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Yes
No
Comment
Consent
*
I hereby declare to have filled out this form truthfully
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