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.
Please give accurate information so you are not confused with other patients
You may choose more than one
Please note we accept patients who can be based in Bali during treatment. BSI does not provide housing or visa assistance, etc.
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.)
Legal citizen of what nation
IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email.
Really helpful to us, thanks !
You may choose as many as you like, together the price is better
Biological gender is needed for accuracy in blood testing
Laboratory blood and urine testing results are based on the age and gender of the patient
We ask so we may properly accommodate specific needs
Example: I have constant bloating and often dizzy. And my joints ache. I just need to feel better.
A genetic blood trait, usually from Greek or African ancestry. If you have this you will probably have known since youth
A serious disease that prevents blood clotting (uncontrolled bleeding). If you have this, you probably will have known since youth
Please choose all that may apply
Example: wheat bread, avocado, orange juice. Don't feel right without them.
If possible, please tell us the names of those you most frequent
Please check all that apply. Comments are greatly appreciated
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.
Your form entry has been saved and a unique link has been created which you can access to resume this form.
Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.
Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.