Health History Questionnaire

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We request all new patients complete The Health History Questionnaire.

Please click Next at the bottom of the page to complete the online form.

If you have difficulty with this online form, You may instead download the PDF version here. When the pdf form is complete, please email to survey@bsi.international

We respect your privacy.

All information is stored on the BSI secure server, no information is available to outside parties.

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Part One : Getting to Know You ...

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Patient Full Name *

Please give accurate information so you are not confused with other patients

Membership *

I am a BSI Member Patient
I am not yet a Member Patient

The last time i received therapy at BSI was... *

I have previously received services or IV therapy at BSI or IV Drips Bali
I have never received services or IV therapy at BSI or IV Drips Bali

The last time I received services or IV therapy at BSI or IV Drips Bali was... *

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Contact *

You may choose more than one

WhatsApp
Telegram
Instagram
Direct Phone
Other

WhatsApp *

Telegram *

Instagram *

Direct Phone *

Other *

Profession(s) *

Working Status *

You may choose more than one

Working full or part time
Not working
On vacation
Retired
Self-employed
Other, please comment

Please comment

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Present Patient Location *

Please note we accept patients who can be based in Bali during treatment. BSI does not provide housing or visa assistance, etc.

Email *

We respect your privacy. Your address will not be given to anyone without your permission. Please note that all correspondence will be via these addresses. Please be sure you can receive email from medical@bsi.international (there is no .com etc.)

Confirm Email

Please choose where you want to see the BSI Doctor... *

Canggu / Tibubeneng, Doctor Vincent, for all services
Ubud / Sanggingan, for all services
GWK / Jimbaran, Doctor Igo, for all services

Nationality *

Legal citizen of what nation

Patient Gender *

Biological gender is needed for accuracy in blood testing

Biological male
Biological female

Referred by Whom *

Really helpful to us, thanks !

Required Testing *

BSI Signature Holistic Health Reset & Detox, Testing & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 4,300,000

Please tell us what additional services you seek at BSI... (optional)

Female Hormones Testing & Therapy, Testing & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 7,700,000
Male Hormones Testing & Therapy, Testing & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 7,700,000
Deep Dive Parasites and Diseases Testing and Remedies Service
* not including prescribed medicines & therapies - Rp. 5,500,000

Please tell us what additional services you seek at BSI... *

BSI Signature Holistic Health Reset & Detox Re-testing, & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 2,760,000
Female Hormones Testing & Therapy, Testing & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 7,700,000
Male Hormones Testing & Therapy, Testing & Diagnosis With Natural Therapies
* not including prescribed medicines & therapies - Rp. 7,700,000
Deep Dive Parasites and Diseases Testing and Remedies Service
* not including prescribed medicines & therapies - Rp. 5,500,000

Total (estimated, not including therapies and medicines)

Rp. 0

The following services are included for free, if requested here in advance. Therapies and medicines quoted after testing is completed. *

You may choose as many as you like, together the price is better

Brain Fog & Memory Testing & Therapy, Testing & Diagnosis With Natural Therapies
Depression & Anxiety Nutraceutical Therapy, Testing & Diagnosis With Natural Therapies
Hypertension (High Blood Pressure) Testing & Therapy, Testing & Diagnosis With Natural Therapies
Insomnia (Sleep Disorders) Testing & Therapy, Testing & Diagnosis With Natural Therapies
NAD Longevity Therapy, NAD Addictions Therapy, Testing & Diagnosis With Natural Therapies
Smoking Cessation Program Testing & Therapy, Testing & Diagnosis With Natural Therapies
Not requested

Please clarify in detail what you are requesting from BSI

When would you like to book an appointment ? *

IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email.

Date

Time

When would you like to book an appointment ? *

IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email.

Date

Time

When would you like to book an appointment ? *

IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email. Innitial appointments are available on Thursdays only, with blood, urine, and feces samples received on the following Friday morning. Test results are scheduled 1 week later, on either Thursday or Friday.

Date

Time

Service Timing Parameters *

I am in Bali for 6 weeks or more, and can receive full services (recommended).
I am in Bali for 3 weeks and can receive accelerated services, with remaining therapies taken home, with email counseling.
I am in Bali 1-2 weeks, and can begin services, with remaining therapies taken home, with email counseling.
I am in Bali for 3-4 business days, and can received initial testing and test results. Therapy will be taken when I return in less than 1 month.
I am in Bali for 1-2 business days, and can receive initial testing only. I can receive results via email, with email counseling in less than 1 week (Extra charge). Therapy will be taken when I return in less than 1 month.
I am in Bali for 1-2 business days, and can receive initial testing only. I can receive results via email, with on-line secure server video counseling for one hour, combined with subsequent email counseling. Video call must be taken in less than one week. (Extra charge). Therapy will be taken when I return in less than 1 month.

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Part Two : Patient Vital Information ...

Are You Able to Care for Yourself, Able to Walk? *

YES, I am able to care for myself and walk
NO, I am incapacitated. Please comment

Present Age in Years *

Laboratory blood and urine testing results are based on the age and gender of the patient

Date of Birth (m/d/y) *

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Faith, Religion, or Practice *

We ask so we may properly accommodate specific needs

Baha'i
Buddhist
Catholic
Hindu
Jewish
Muslim
Protestant
Self-aware / fully awakened
Other not listed here
Not religious

Please comment

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Part Three : Patient Request for Services ...

Please Fully Describe the Illness or Concerns *

Example: I have constant bloating and often dizzy. And my joints ache. I just need to feel better.

Present Weight *

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Present Height *

Present height
I have been taller than now
My height has changed from osteoporosis, scoliosis or other bone disease. Please describe.

Present height

I have been taller than now

My height changed from osteoporosis, scoliosis or other bone disease. Please describe.

Blood Type (if known) *

A+
A-
B+
B-
AB+
AB-
O+
O-
Don't know

Blood Thalassemia *

A genetic blood trait, usually from Greek or African ancestry. If you have this you will probably have known since youth

No, I do not have Thalassemia
Yes, I have Thalassemia

Hemophilia *

A serious disease that prevents blood clotting (uncontrolled bleeding). If you have this, you probably will have known since youth

No, I do not have Hemophilia
Yes, I have Hemophilia

Describe Your Exercise Habits *

Please choose all that may apply

Type 0: Not much. Sedentary
Type 1: Occasional short walking, relaxation
Type 2: Yoga, Pilates, stretching etc. Occasionally raise heart rate high
Type 3: Occasional or frequent running, jumping, trampoline, jogging , horseback (lymphatic stimulation and impact exercise)
Type 4: Weight lifting, muscle building, (endurance training)
Type 5: Super Athletic, trains or works out nearly daily.

Stress Level *

1 (No or very little stress, easy going, content)
2 (Normal stresses of managing a home or local environs, but happy)
3 (Normal stresses of challenging work or relationship, could use more rest)
4 (Moderate work stresses, challenging emotions, a little cranky but coping)
5 (Moderate or higher stresses from disease and / or home life / work life, need time off but can’t)
6 (Very stressed and emotional, need distance, occasional snapping / yelling at others)
7 (Mild anger or sadness much of the time. Work hard to avoid conflict with others, may be taking related medications)
8 (Outraged most of the time, depressed, nothing makes sense, over-saturated with surroundings and society, yelling or striking at others)
9 (No hope, no patience, beyond ability to be calm or relaxed, unable to sleep)
10 (Totally unable to function in the world, restrained from public contact, fully anti-social)

Please enter your comment here

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Time I normally go to bed *

Time I normally awaken *

Nap *

I do not take naps
I nap (how many times per week)
I usually nap for how many minutes when i nap

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I nap (how many times per week) *

I usually nap for how many minutes when I nap *

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Normal Sleep Habits *

I am told I snore at night
I recover from jet lag with difficulty
I have difficulty falling asleep
I fall into a deep sleep
My sleep hours are enough
I feel vigorous after sleep
I am satisfied with my sleep
I have a clear head after sleep
I wake up while sleeping
I wake up easily because of noise
I have difficulty getting back to sleep once I wake up in middle of the night
I toss and turn
I never go back to sleep after awakening during sleep
Poor sleep gives me headaches
Poor sleep makes me irritated
Poor sleep makes me lose my appetite
Poor sleep makes it hard for me to think
Poor sleep makes it hard to concentrate
Poor sleep makes me lose interest in work or others
Poor sleep makes me forget things more easily
Poor sleep makes me lose desire in all things
Sleepiness interferes with my daily life
I have difficulty getting out of bed
I would like to sleep more after waking up
I feel refreshed after sleep

Please enter your comment here

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Part Four : General Health Questions ...

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Usual Diet. Does the Patient Consume these Weekly or Daily? *

Wheat products (bread, pasta, noodles etc.)
Sweet bakery items (donuts, cakes, cookies, etc.)
Sweets, candies, chocolate, etc. each day
Need to eat something sweet in or with most or all meals
Common junk foods, chips, cakes, candies, etc
Dairy products (milk, ice cream, cheese, yoghurt, etc.)
Soy products (tofu, tempeh, soy sauce, soy flour etc.)
Processed, pre-packaged meats (canned meats of any kind, meat mixtures, bacon, lunch meats, sausage, etc.)
Consume boxed, canned, bagged, pre-made foods from super markets (cereals, frozen meals, etc.)
Low-grade fats, (oils of soy, canola, corn, highly processed oils, hydrolyzed shortening, etc.)
Juices, cold-pressed juices, smoothies, shakes, etc.
Powdered foods (spirulina, chlorella, whey, athletic blends, etc.)
Soups, stews, etc.
Coffee, tea, ginseng, chocolate (caffeine containing foods or beverages)
Alcohol, beer, wine, mixed drinks. How often, and what type
Clean fresh water. I drink how much each day
“White foods” (white rice, white noodles, white breads, white sugar, white milk, white salt, etc.)
Raw foods (salads, nuts, sushi, etc.)
Seed oils such as cotton seed, soy, canola, corn, palm, etc.
Clear extra virgin coconut oil (EVCO) or extra virgin olive oil
Wild or semi-wild foods, such avocado, mango, coconut, fresh ocean fish, berries, etc.
Other not listed above. Please explain.

Please enter you comment here

Foods and Beverages Consumed DAILY *

Example: wheat bread, avocado, orange juice. Don't feel right without them.

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Do You Eat in Restaurants / Cafes / Street Vendors, etc? *

If possible, please tell us the names of those you most frequent

Almost never
1-3 times per week
3-6 times per week
1 time each day
2 times each day
3 times each day

Please enter your comment here

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Nutritional Supplements *

Vitamin A / total daily
Vitamin B Complex or singular B vitamins / total daily
Vitamin C tablets, pills, powders, etc. / total daily
Vitamin D / total daily
Vitamin E / total daily
Minerals, combined or singular / total daily
Green powders, spirulina, chlorella, etc. / total daily
Body building powders / drinks, etc. / when and how much
Probiotics. Please name type and how often.
Herbal supplements / teas, powders, etc.
BSI Therapure Nutraceuticals consumed presently or in the past
Injectable supplements / when and totals
Other nutritional items not listed here
None of the above

Please enter your comment here

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General Health Questions *

Chronic or occasional pain. Please describe
Recent fever
New injuries. Please describe
Old injuries. Please describe
Cold chills or cold sweats
High blood pressure
Low blood pressure
Legs and feet (swelling, stiff joints, etc.)
Arteriosclerosis (blocked arteries)
Never or none of the above

Please enter your comment here

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Brain and Head Area *

Balding, hair loss, blotchy hair, Is the patient's hair thinning or falling out prematurely
Pressure headaches
Throbbing headaches
Back-of-the-head headaches
Forehead headaches
Headaches around or behind eyes
Memory lapses
Dizziness or fainting
Diagnosed with a tumor or brain disease
Brain or head injuries at any time in life
Brain surgery
Nervousness, shaking, lack of motor control, etc.
Paralysis anywhere in the body
Lack of feeling anywhere in the body
Over-sensitivity anywhere in the body
Stroke
Scalp problems, dandruff, itching, flaking, etc.
Tumors, growths, moles, warts, etc. on the scalp or head
Other head surgeries, such as on the ear, nose, neck etc.
Something not listed above
None of the above

Please enter your comment here

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Oral & Dental *

I have very healthy teeth and gums
I have missing teeth, how many
I have chipped or partial teeth
I have diseased or rotting teeth
I have bleeding gums
I have receding gums
I have false teeth or dentures
All or most original teeth been removed
I have amalgam fillings, how many
I have ceramic fillings, how many
I have dental caps or crowns on original teeth
I have new style, more recent root canals
I have old style root canals
I wear or have worn braces
I have dentures or bridges
I have ulcers or growths in my mouth or my tongue
I have or have had oral herpes
I have lost my sense of taste or smell
I use commercial mouth wash
I am told I have bad breath most of the time
I have excessive amounts of mucous or saliva

Please enter your comment here

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Thyroid Disorders / Swelling *

Taking thyroid medication
Undergone thyroid surgery or removal
Thyroid area inflammed or in pain
Exposed to nuclear radation that may have affected the thyroid
Never or not sure

Please enter your comment here

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Sinus, Ears, Throat *

Recent or previous ear and/or sinus infections
Any swelling or pain in the throat area
Undergone surgeries in the throat or on the neck
Recent or previous swollen or painful lymph glands in the neck or throat area
Strained or dry voice
Lumps or hard nodules anywhere in the mouth, sinus, gums
Difficulties swallowing
Sticky mucous in the throat area
Something not listed above
Never or note sure on all the above

Please enter your comment here

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Eyes *

Objects floating in vision
Tunnel vision
Poor night vision
Wear corrective lenses
Eye surgery (alignment, Lasix, repair, etc.)
Full or partial blindness
Something not listed above
None of the above

Please enter your comment here

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Digestive System *

Difficulty when swallowing
Specific digestive issues of the liver, gallbladder, pancreas, stomach, intestines, etc.
Diabetes / hypoglycemia / sugar cravings
Sometimes or often constipated
Bloating, indigestion, vomiting, excessive gas, etc.
Occasional or frequent diarrhea
Feces are strange color, grey, yellow, green, red, black
Rectal bleeding, or blood in stool
Hemorrhoids (piles)
Anal itching or irritation
Cramping, abdominal pain
Any other digestive condition not on the above list
Never or none of the above

Please enter your comment here

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Respiratory System *

Asthma / lung disorders
Shortness of breath
Chronic cough and/or chest pain
Frequent infections
Sinus and/or ear infections. They are treated how
Other problems not on this list
Never or none of the above

Please enter your comment here

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Smoking *

Tobacco cigarettes, what brand(s), how often, from when to when please
Vaping. What brand(s), how often, from when to when please
Cigars, pipes, chewing tobacco, etc.
Substances other than tobacco
Never or none of the above

Please enter your comment here

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Kidneys, Adrenal Glands, Bladder, Urinary Tract *

Please check all that apply. Comments are greatly appreciated

Urinary tract surgery. Cause and results
Growths or eruptions on or around genitalia
Swollen lymph or lumps in around the anus, perineum, genitals, and surrounding areas
Pain or discomfort during sex
Take diuretics to facilitate urination
Urinary tract infections. Recent or frequent
Burning or difficult urination
Awakened at night to urinate. How many times
None of these or other response

Please enter your comment here

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Heart and Circulatory System *

Please check all that apply. Comments are greatly appreciated

Arrhythmia (irregular heartbeat)
Tachycardia (abnormally fast heart rate)
Bradycardia (abnormally slow heart rate)
Ever suffered a heart attack
Chest pains in or around the heart
Heart or related surgeries or therapies
Blood disorders
Other answer not listed above
Never, none of these

Please enter your comment here

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Skin and Body Surface *

Please check all that apply. Comments are greatly appreciated

Excessive sweating or body odors
Dry or scaly skin
Growths, skin infections, skin irrgularities of any kind on the body. Where, please describe
Excessive bruising, discoloration or spots
Varicose veins / Thrombophlebitis
Cosmetic skin peels / Glycolic Acid, etc.
Have you ever injected Botox or similar
Fingernail or toenail changes. Please describe
Skin surgeries / transplants of any kind. Result
Treated for skin cancer or other growth. Where on the body, and when
Problems not listed above
Never or none of these

Please enter your comment here

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Male Considerations *

Please check all that apply. Comments are greatly appreciated

Prostate issues – surgery, pain, etc.
Erectile problems
Any strange discharge or irritation of the penis
Testicle problems – swelling, discoloration, surgery, etc.
Sexually transmitted diseases (STDs). Now or in the past that may have affected your concerns here
Taking hormones of any kind that affect reproduction
Other condition not on this list. Please describe here
Never or none of these

Please enter your comment here

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Female Considerations *

Please check all that apply. Comments are greatly appreciated

Surgery of the reproductive system. Please answer when, reason, and result
Pregnant now
Using bith control of any kind. What type, for how long
Taking hormones of any kind that affect reproduction
Currently menstruate on a consistant cycle
Are menses very heavy or very light, of strange duration. Please comment.
Menopause. How long. Difficulties.
Sexually transmitted diseases (STDs). Now or in the past
Vaginitis, pain, or or vaginal discharge
Endometriosis
Breast issues (swollen lymph, pain, etc.)
Other condition not listed here
Never or none of these

Please enter your comment here

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Projected beginning of cycle *

Projected end of cycle *

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Purpose of Testing: (when performing full testing, not just specific hormones) Please be sure to schedule hormone testing in sync with menstruation. Please choose your concerns below *

General hormonal function: Any time outside of menstruation
PCOS: Anytime outside of menstruation
Fertility / Ovarian function: Test on day 3 (but cannot do urine testing this day)
Menopause / Peri-menopause : Day 3 (but cannot do urine testing this day)
Heavy emotions: Around days 19-22
Light or Heavy menses: Around days 19-22
Specific concerns about Estrogen or Progesterone: Days 19-22
Missing period: Any time

Please enter your comment here

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Allergies *

Animals
Certain drugs
Diary products
Dust
Mold or mildew
Nuts or seeds
Other allergens not listed
Never or not sure

Please enter your comment here

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Autoimmune Disorders *

Alopecia areata. Sudden hair loss that starts with one or more circular bald patches that may overlap.
Ankylosing spondylitis. An inflammatory arthritis affecting the spine and large joints.
Celiac disease. An immune reaction to eating gluten, a protein found in wheat, barley and rye.
Lupus. An inflammatory disease caused when the immune system attacks its own tissues.
Multiple sclerosis. A disease in which the immune system eats away at the protective covering of nerves.
Polymyalgia rheumatica. An inflammatory disorder causing muscle pain and stiffness around the shoulders and hips.
Rheumatoid arthritis. A chronic inflammatory disorder affecting many joints, including those in the hands and feet.
Sjögren’s syndrome. An immune system disorder characterised by dry eyes and dry mouth.
Temporal arteritis. An inflammation of blood vessels, called arteries, in and around the scalp.
Type 1 diabetes. A chronic condition in which the pancreas produces little or no insulin.
Vasculitis. An inflammation of the blood vessels that causes changes in the blood vessel walls.
Other conditions not listed above.
Never or not sure.

Please enter your comment here

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Cancers *

I now have cancer, or previously had cancer. Please comment
Stage and type of cancer (if any, in detail please)
Results of any previous medical tests.
Intravenous chemotherapy
Oral chemotherapy
Hormone therapy
Radiation therapy
I have received holistic or natural therapy for cancers and related diseases
Other not listed here. Please explain.
Never, or not sure

Please enter your comment here

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Hepatitis or Liver Disease *

Yellowing of the eyes or skin
Hepatitis A (HAV) (Hepatitis A is spread primarily through food or water contaminated by stool from an infected person. Hepatitis A is a food-borne or waterborne illnesses.)
Hepatitis B (HBV) (The hepatitis B virus is spread through blood, semen, or other body fluids.)
Hepatitis C (HCV) (The hepatitis C virus is spread through contact with an infected person’s blood — because of genital sores or cuts or menstruation. Also through injection drug use, unsafe injection practices, unsafe health care, and the transfusion of unscreened blood and blood products.)
Hepatitis D. (HDV) (Hepatitis D infection only occurs in the presence of hepatitis B virus.
HDV-HBV co-infection is considered the most severe form of chronic viral hepatitis.)
Hepatitis E (HEV) (The hepatitis E virus is transmitted mainly through contaminated drinking water. It is usually a self-limiting infection and resolves within 4 to 6 weeks.)
NON-viral Hepatitis. Please describe
Never or none of the above

Please enter your comment here

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Herpes *

Herpes Simplex 1 (HSV-1) (oral cold sores in or around the mouth or lips. Associated with bipolar disorder, Alzheimer’s disease and more)
Herpes Simplex 2 (HSV-2) (gential / anal area breakouts. Associated with (Mollaret’s meningitis)
Herpes 3 (HHV-3 or VZV) (chickenpox, shingles, human herpes varicella-zoster)
Herpes 4 (Epstein Barr HHV 4) (associated with mononucleosis, lymphomas, lupus, arthirtis, MS, Chronic Fatigue, etc.)
Herpes 5 (cytomegalovirus HHV 5 or CMV (associated with Infectious mononucleosis (‘kissing disease’), retinities)
Herpes 6 (HHV-6) (associated with Chronic Fatigue Syndrome, cognitive dysfunction, autonomic dysfunction, roseolovirus, lymphotroponic virus – infects approximatly 70% of humans. Symptoms consistent with hepatitis and encephalitis)
Herpes 7 (HHV-7) (associated with pityriasis rosea. Also associated with drug-induced hypersensitivity syndrome, encephalopathy, hemiconvulsion-hemiplegia-epilepsy syndrome, hepatitis infection, postinfectious myeloradiculoneuropathy, pityriasis rosea, and the reactivation of HHV-4, leading to “mononucleosis-like illness”))
Herpes 8 (HHV-8) (Associated with neoplasms. Diseases caused by HHV-8 infection include Kaposi Sarcoma, Multicentric Castleman Disease (MCD), Primary Effusion Lymphoma (PEL), which occur primarily in patients with HIV infection)
ParvoVirus (B-19) (associated with slapped cheek syndrome, sero negative arthiritis, aplastic anemia, sickle cell disease, encephalitis, meningitis, stroke, peripheral neuropathy, and more)
Not sure or other condition not listed above. Please explain
Never or none of these

Please enter your comment here

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Toxic Exposures *

Exposed to chemicals or toxins related to machine work, solvents, fuels, industrial cleaners, etc.
Insect or weed killers in the house or around where you are (how often, what brand)
Insect repellants sprayed or rubbed onto the body (how often, what brand)
Briefly describe any toxic chemical exposures at any time during your life
Party favors in the past three years
Other exposures not listed above. Please explain
Never or none of the above

Please enter your comment here

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Radioactivity Exposures *

Radioactive exposures from frequent flying (how many flights per year)
Radioactive exposures from CT scans, MRI, X-rays. How many times. Contrast injected into the body during the proceedure
Use of cell phone next to the head (how many hours per day on average)
Live within 100 meters of a cellular or radio broadcast tower. Please explain.
I have lived or worked near a nuclear power plant or nuclear facility
I have lived near or visited Chernobyl, Fukushima, Hanford or other contaminated area
I have suffered from unexplained sudden hair loss or skin mottling, etc.
Any other source of radioactivity not listed above. Please explain
Never or none of the above

Please enter your comment here

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Common Medications the Patient has Taken during the Past 2 Years or Less *

Aspirin / Other pain killers
Ibuprofen (Advil / Motrin)
Panadol / Paracetamol / Tylenol / Benadryl / Acetaminophen
Sudafed / Claritin / anti-histamine
Diuretics (ease urination)
Coumadin/ Heparin/ blood thinners (stroke prevention)
Statins for cholesterol, (Lipitor, Crestor, Zocor)
Prozac or similar
Anti-fungal (on skin or orally)
Estrogen / HGH / other hormones
Other not listed above. Please describe. Thanks.
None of these

Please enter your comment here

All CURRENT medications, supplements, herbal medications, etc. you are taking *

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Vaccines or Inoculations – Did you have reactions ? If so, how and where? Did you experience the covid infection afterward ? Have you received these over the years? *

Have you received these over the years? All answers are fully confidential VERY IMPORTANT. Your complete answers will help us to better diagnose problems. If known, please tell us when with comments regarding reactions, etc.

COVID 19 – FIRST SHOT – Please indicate BRAND NAME (Johnson & Johnson, AstraZeneca, Moderna, Pfizer, BioNtech, Sinovac, etc.) Please also indicate DATE and PLACE or CLINIC the shot was received (very important). Did you have reactions? Please explain.
COVID 19 – SECOND SHOT – Did you have reactions? Please explain.
COVID 19 – FIRST BOOSTER SHOT – Did you have reactions? Please explain.
COVID 19 – SECOND BOOSTER SHOT – Did you have reactions? Please explain.
COVID 19 – THIRD BOOSTER SHOT – Did you have reactions? Please explain.
COVID 19 – FOURTH BOOSTER SHOT – Did you have reactions? Please explain.
COVID 19 – FIFTH BOOSTER SHOT – Did you have reactions? Please explain.
COVID 19 – SIXTH BOOSTER SHOT – Did you have reactions? Please explain.
How many times have you taken the PCR / Swab
Chickenpox (Varicella)
Cholera
Current flu vaccination every flu season
Diphtheria-tetanus-pertussis (DTP) vaccine
Haemophilus influenzae type b (Hib)
Hepatitis A
Hepatitis B
HPV vaccine
Japanese Encephalitis
Malaria
Measles-mumps-rubella (MMR) vaccine
Meningococcalconugate vaccine
Meningitis
Pneumococcal (PCV)
Polio vaccine
Rabies
Rotavirus (RV)
Td or Tdap vaccine (tetanus, diphtheria, and pertussis) booster each 10 years.
Typhoid and paratyphoid fever
Varicella (chickenpox) vaccine
Yellow Fever
Zoster vaccine
Other vaccination not listed above, please explain
Not sure

Please enter your comment here

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Antibiotics in the Past 10 Years *

Amoxicillin. A penicillin antibiotic prescribed for tonsillitis, bronchitis, pneumonia, gonorrhea, and infections of the ear, nose, throat, skin, or urinary tract, and more.
Amoxicillin / Clavulanate. A combination penicillin antibiotic that fights bacteria in the body.
Azithromycin. Given for respiratory, skin, and ear infections, and sexually transmitted diseases.
Cephalexin. Prescribed for upper respiratory infections, ear infections, skin infections, and urinary tract infections.
Ciprofloxacin (fluoroquinolone). Prescribed for anthrax, plague, stomach disorders and more.
Clindamycin. A wide-spectrum antibiotic that fights bacteria in the body.
Doxycycline. For urinary tract infections, intestinal infections, eye infections, gonorrhea, chlamydia, periodontitis (gum disease), and others.
Levofloxacin (fluoroquinolone). For skin, sinuses, kidneys, bladder, prostate, bronchitis, pneumonia, anthrax.
Metronidazole (Clindamycin hydrochloride). A strong wide spectrum antibiotic that fights bacteria in the body.
Sulfamethoxazole / Trimethoprim. Used to treat or prevent wide spectrum of bacterial infections.
An antibiotic not on this list.
Exposure from foods such as chicken, eggs, fish, meat, etc.
Never have taken antibiotics.

Please enter your comment here

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Happiness and Well Being *

I am generally happy and content…
My strengths are…
My weaknesses are…
I suffer / have suffered from depression…
I suffer / have suffered from anxiety…
I have taken / take medications for depression or anxiety…
I am easily angered, triggered by…
I practice / have practiced a form of mind centering, such as meditation or quiet time…
Other answer not listed above

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Therapies Received in the Past 2 Years or Now Receiving *

Acupuncture
Aromatherapy
Chelation therapy
Colonic therapy
Detoxing
Cannabis
Chemotherapy
Herbal medicine
Homeopathy
Naturopathy
Oxygen therapy
Prolo Therapy
Radiation Therapy
Reiki
Vitamin C infusions (dosage, how often, any side effects)
Other therapy not on this list
Never or none of the above

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Surgeries and Operations *

Appendix removed
Tonsils removed
Digestive surgeries
Elective surgeries. Please explain
Plastic surgeries. Please explain
Liposuction
Emergency surgeries
Eye operations
Heart
Skin operations, including growths or cancers, etc.
Other surgeries not listed above, please explain here
None of the above

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Anti-Fungal Medicines *

Oral anti-fungal medicines
Topical anti-fungals
Not sure or other medicine, please explain
Never or none of the above

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Parasites *

Treated for digestive parasites. If so when and how. Did the treatment work
Treated for skin or hair parasites
Frequent bloating or gas
Anal bleeding or itching
Strings or mucous in the stools
I live with dogs or cats
I swim in tropical rivers or lakes
I eat raw foods
Other parasite problems not listed here. Please explain
Never or none of these. Please explain

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Anything Else of Relevance *

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