Personal questionnaire for the confidential health check with recommendation of therapy

Please fill out this questionnaire, all-embracing and truthfully. Only this way we are able to recommend you the right therapy. Your data will not be given to a third party and will only be saved until you have reached your decision..

Step ¼


Symptoms (pain/ disease)

Do you suffer from a chronic illness?

Do you suffer from relapsing pain lately?

Do you have physical impairments?

Do you consume alcohol (glasses of wine 0.2l, bottle of beer 0.5l)?

If yes, how often?

When did you not consume alcohol for two days in a row?
In that time, did you have symptoms, e.g. tremor, attacks of sweating or insomnia/ sleeplessness?

Do you take medication?

Do you take other drugs (Cocaine, amphetamines, cannabis among others)?