Information sheet

Fill in the form below, press submit at the bottom. Fields marked * must be filled in:

Family Diseases

01 - Heart/circulatory diseasesYesNo

02 - Cancer illnessesYesNo

03 - Metabolic disordersYesNo

03a - DiabetesYesNo

04 - Nervous diseases (paralysis, cramps, migraine, epilepsy)YesNo

05 - Mental illnessesYesNo

Own Diseases

06 - Infectious diseasesYesNo

07 - Frequent or severe headacheYesNo

08 - Concussion, dizziness or seasicknessYesNo

09 - Migraine, fainting, epilepsy or crampsYesNo

10 - Sneezing, asthma, allergy or eczemaYesNo

11 - Ear (deafness), nose or throat diseasesYesNo

12 - Eye diseases (weak vision, double vision, blurred vision)YesNo

13 - Heart-circulatory disordersYesNo

14 - Respiratory diseases (bronchitis, shortness of breath)YesNo

15 - Gastrointestinal diseases (diarrhea, constipation)YesNo

16 - Acid stomach, anal itchingYesNo

17 - Kidney, bladder or urinary tract disordersYesNo

18 - Diseases of bones, muscles and jointsYesNo

19 - Metabolic diseasesYesNo

20 - Psychological disorders (nervousness, insomnia)YesNo

21 - Malformations, defects, other diseasesYesNo

22 - Bruises easily when bumpedYesNo

23 - Injuries, accidents or poisoningYesNo

24 - Hospital admissionsYesNo

If "Yes" - year, for what and possible nuisances now:

25 - Root-treated or bad teethYesNo

26 - Craving for sweetsYesNo

27 - Uses glasses/hearing aidsYesNo

29 - Weekly hours at work

Hours

30 - Foreign travel, weeks/year

Weeks

31 - Exercise typeWalkRunBiking

Other

32 - IntensityVery active (>4 hours/week)SActive (2-4 hours/week)Less active (1-2 hours/week)Passive (0-1 hour/week)

34 - DietFull dietDiet low in fat and sugarVegetarian diet

Weight change

35 - Change in weight within 1 year

kg.

36 - Weight in your 20s

kg.

37 - Weight now

kg.

38 - Height

cm.

Daily tobacco consumption

39 - Cigarettes, quantity

40 - None since

41 - Never smokedYes, I have never smoked

43 - Coffee/tea - number of cups per day

44 - Medicine

45 - Dietary supplements

46 - Current issue

47 - Date of birth*

48 - Full name*

49 - Email**

55 - Do you want to inform your own doctor?YesNo

56 - Do you agree that the clinic may see previous blood samplesYesNo

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“THE DOCTOR’S GUIDE TO NATURAL HEALTH”

Lecture with Søren Flytlie

SEE MORE HERE