New Patient Questionnaire

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We request all new patients complete The New Patient Questionnaire. Please click Next at the bottom of the page to complete the online form.

Important Instructions

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2) If you want to pause and restart at another time, please click the “VERY IMPORTANT…” link at the bottom of this page.

3) For your benefit, please fully answer all questions, as the basis of your analysis is a detailed medical history.

4) We respect your privacy. Your New Patient Questionnaire is hosted on our private secure server. No information is given to outside parties, nor is it stored in the so-called cloud.

VERY IMPORTANT : If you need to leave this questionnaire, please click here to generate a code to resume at any time within the next 30 days.

Part One : Getting to Know You …

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Patient Full Name *

We request 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 *

Please indicate if W/A, Telegram, or direct phone. You may choose more than one. We need to be able to contact you in the event of schedule change or important notification. We respect your privacy.

WhatsApp
Telegram
Instagram
Direct Phone
Other

WhatsApp *

Telegram *

Instagram *

Direct Phone *

Other *

Profession(s) *

We ask so that we may understand your availability for examination and sources of stress.

Working Status *

We ask so that we may understand your availability for examination and sources of stress. You may choose more than one.

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

Other, 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 *

Important : All correspondence is via this email address. We respect your privacy. Your address will not be given to anyone without your permission. Please note that all correspondence will be via this address. 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 / Berawa, Doctor Frieda, for all services
Ubud / Sanggingan, Doctor Wisnu, for all services
GWK / Jimbaran, Doctor Igo, for all services

Nationality *

Legal citizen of what nation

When would you like to book an appointment ? *

IMPORTANT, Please note: we will try to give you this appointment date, but this is not guaranteed. You will be informed via return email when your appointment has been made.

Date

Time

Referred by Whom *

Really helpful to us, thanks !

Please tell us what services you seek at BSI. You may combine services as needed. *

BSI Signature Holistic Health Reset & Detox, Testing & Diagnosis With Natural Therapies
Brain Fog & Memory Testing & Therapy, Testing & Diagnosis With Natural Therapies
Covid Effects & Testing, Testing & Diagnosis With Natural Therapies
Dengue Testing & Therapy, Testing & Diagnosis With Natural Therapies
Depression & Anxiety Nutraceutical Therapy, Testing & Diagnosis With Natural Therapies
Female Hormones Testing & 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
Male Hormones Testing & Therapy, Testing & Diagnosis With Natural Therapies
Parasites Testing & Therapy, Testing & Diagnosis With Natural Therapies
Smoking Cessation Program, Testing & Diagnosis With Natural Therapies
Super Bugs / Immunities Enhancement Testing & Therapy, Testing & Diagnosis With Natural Therapies
Youth Preservation, Testing & Diagnosis With Natural Therapies

Please clarify in detail what you are requesting from BSI

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. 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.

VERY IMPORTANT : If you need to leave this questionnaire, please click here to generate a code to resume at any time within the next 30 days.

Part Two : Patient Vital Information …

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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

Please comment *

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Patient Gender *

Biological gender is needed for accuracy in blood testing

Biological male
Biological female
Different options

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 *

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

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Faith, Religion, or Practice *

We ask so we may properly accommodate specific needs. You may choose more than one.

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

Please comment

VERY IMPORTANT : If you need to leave this questionnaire, please click here to generate a code to resume at any time within the next 30 days.

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 *

Also, please tell us the ideal or normal weight
Example: Presently 52 Kilos. Dropped from 68 kilos in 6 months. Ideal weight is 50 kilos.

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Present Height *

Present height?
Have you ever been taller than now?
Height changed from osteoporosis, scoliosis or other bone disease? Please describe.

Present height?

Have you ever been taller than now?

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, light to moderate swimming etc. Occasionally raise heart rate high
Type 3: Occasional or frequent running, jumping, trampoline, jogging (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 *

On a Scale of 1 to 10 (10 being the strongest stress), what is your current stress level. If possible, please describe

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 *

Please choose all that may apply

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

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 a 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

VERY IMPORTANT : If you need to leave this questionnaire, please click here to generate a code to resume at any time within the next 30 days.

Part Four : General Health Questions …

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

Please describe in the comment boxes, details are helpful.
These items are not necessarily bad or good, nor is this a judgement. We ask your honest answers to help us analyze your current health needs. Please note: By ticking a box, your answer means ‘yes’ NOT ticking the box means ‘no’ or does not apply. Example: I eat raw salads with smoothies most days.

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.

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, 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 drink. 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, such as 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.

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

Comment

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Nutritional Supplements – Total daily / weekly / monthly *

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

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 – please tell us which ones have been most helpful to you

Injectable supplements / when and totals

Other nutritional items not listed here

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General Health Questions *

These answers help to analyze current health conditions. Comments are very helpful, please answer in detail

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

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)

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Brain and Head Area *

Have you experienced any of the following? Please explain if possible

Balding, hair loss, blotchy hair, 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

Balding, hair loss, blotchy hair, 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

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Oral and 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 comment

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Thyroid Disorders / Swelling *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

Taking thyroid medication?

Undergone thyroid surgery or removal?

Thyroid area inflammed or in pain?

Exposed to nuclear radation that may have affected the thyroid?

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Sinus, Ears, Throat *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

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

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

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Eyes *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

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 ?

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Digestive System *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

Difficulty when swallowing ?
Specific digestive issues of the liver, gallbladder, pancreas, stomach, intestines, etc. Please explain.
Do you have diabetes / hypoglycemia / sugar cravings ?
Sometimes or often constipated ?
Bloating, indigestion, vomiting, excessive gas, etc ?
Occasional or frequent diarrhea ?
Are the feces a 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

Difficulty when swallowing ?

Specific digestive issues of the liver, gallbladder, pancreas, stomach, intestines, etc. Please explain.

Do you have diabetes / hypoglycemia / sugar cravings ?

Sometimes or often constipated ?

Bloating, indigestion, vomiting, excessive gas, etc ?

Occasional or frequent diarrhea ?

Are the feces a 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 ?

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Respiratory System *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

Asthma / lung disorders ?

Shortness of breath ?

Chronic cough and/or chest pain ?

Frequent infections ?

Sinus and/or ear infections ? How are they treated ?

Part Five : Patient Diseases and Causes …

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Allergies *

Do you experience allergic reactions to the following. What are the symptoms, and remedies taken? Please ONLY tick the boxes that may apply to you. Example: If I am anywhere near cats I break out in hives.

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

Animals?

Certain drugs?

Diary products?

Dust?

Mold or mildew?

Nuts or seeds?

Other allergens not listed?

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Autoimmune Disorders *

Do you currently or in the past suffer from any of these? Please tick all boxes that may apply. Add comments as needed. Example: My arthritis gets worse when I eat sugar.

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.

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.

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Cancers *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

Do you 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. (Please provide most recent copies when we meet – please do not include here)
Results of biopsy, if any
Intravenous chemotherapy?
Oral chemotherapy?
Hormone therapy?
Radiation therapy?
Holistic or natural therapy for cancers and related diseases?
Other not listed here. Please explain.
Never, or not sure

Do you 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. (Please provide most recent copies when we meet – please do not include here)

Results of biopsy, if any

Intravenous chemotherapy?

Oral chemotherapy?

Hormone therapy?

Radiation therapy?

Holistic or natural therapy for cancers and related diseases?

Other not listed here. Please explain.

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Hepatitis or Liver Disease *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of 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

Yellowing of the eyes or skin?

Hepatitis A (HAV)

Hepatitis B (HBV)

Hepatitis C (HCV)

Hepatitis D (HDV)

Hepatitis E (HEV)

NON-viral Hepatitis. Please describe

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Herpes *

Do you have or have had any of the 8 types of herpes virus? These virus are considered the basis of most common disease today. Please study these answers carefully and check all boxes that may apply. Comments are helpful. Example: I have outbreaks inside my lower lip once or twice per year.

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

Herpes Simplex 1 (HSV-1)

Herpes Simplex 2 (HSV-2)

Herpes 3 (HHV-3 or VZV)

Herpes 4 (Epstein Barr HHV 4)

Herpes 5 (cytomegalovirus HHV 5 or CMV)

Herpes 6 (HHV-6)

Herpes 7 (HHV-7)

Herpes 8 (HHV-8)

ParvoVirus (B-19)

Not sure or other condition not listed above. Please explain

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Toxic Exposures *

Please check all boxes that may apply. Dates and comments are helpful. Example: I worked on a farm for many years until 6 months ago, and have been exposed to many weed and bug killers.

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 the Patient’s life
Party favors in the past three years
Other exposures not listed above. Please explain
Never or none of the above

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 the Patient's life

Party favors in the past three years

Other exposures not listed above. Please explain

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Radioactivity Exposures *

Please check all boxes that may apply. Comments are very helpful. Example: I frequently fly over the north Pacific. Often have coughing afterward.

Radioactive exposures from frequent flying (how many flights per year?)
Radioactive exposures from CT scans, MRI, X-rays. How many times? Was ‘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.
Have lived or worked near a nuclear power plant or nuclear facility?
Have lived near or visited Chernobyl, Fukushima, Hanford or other contaminated area?
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

Radioactive exposures from frequent flying (how many flights per year?)

Radioactive exposures from CT scans, MRI, X-rays. How many times? Was '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.

Have lived or worked near a nuclear power plant or nuclear facility?

Have lived near or visited Chernobyl, Fukushima, Hanford or other contaminated area?

Have suffered from unexplained sudden hair loss or skin mottling, etc?

Any other source of radioactivity not listed above. Please explain

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Part Six : Medications Past and Present …

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

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

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.

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

If possible, please give the name of each medication, amount taken, and purpose. Example: I take 1 aspirin every day to thin the blood.

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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? *

It’s okay if vaccinated or not, no problem. Fully private information. We need to know so we can give proper diagnosis. Thanks! 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).

COVID 19 – FIRST SHOT – 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.
PCR SWAB – How many times have you taken the PCR / Swab ? It’s okay if you have taken the PCR test or not, no problem. Fully private information. We need to know so we can give proper diagnosis. Thanks! Did you experience reactions ? If so, did you lose your sense of taste or smell ? Did you get a covid infection afterward ?
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

COVID 19 – FIRST SHOT

COVID 19 – SECOND SHOT

COVID 19 – FIRST BOOSTER SHOT or more

COVID 19 – SECOND BOOSTER SHOT or more

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

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Antibiotics in the Past 10 Years *

These questions are very important for proper diagnosis of disease, because many antiobiotics can affect immunities for 5 years or longer. Please give your best answers – Thanks ! Please add when and why taken. Example: I took Amoxicilin in 2017 for a viral throat infection.

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.

Amoxicillin

Amoxicillin / Clavulanate

Azithromycin

Cephalexin

Ciprofloxacin (fluoroquinolone)

Clindamycin

Doxycycline

Levofloxacin (fluoroquinolone)

Metronidazole (Clindamycin hydrochloride)

Sulfamethoxazole / Trimethoprim

An antibiotic not on this list.

Exposure from foods such as chicken, eggs, fish, meat, etc.

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Part Seven : Therapies Past and Present …

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Happiness and Well Being *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

Iam 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, please comment

Iam 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, please comment

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Therapies Received in the Past 2 Years or Now Receiving *

Please tick all that may apply. Comments are appreciated and helpful in prescription.

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

Acupuncture

Aromatherapy

Chelation therapy

Colonic therapy

Detoxing

Cannabis

Chemotherapy

Herbal medicine

Homeopathy

Naturopathy

Oxygen therapy

Prolo Therapy

Radiation Therapy

Reiki

Vitamin C infusions

Other therapy not on this list

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Surgeries and Operations *

Please add when and why performed, plus results

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

Appendix removed

Tonsils removed

Digestive surgeries

Elective surgeries. Please explain

Emergency surgeries

Eye operations

Heart

Skin operations, including growths or cancers, etc.

Other surgeries not listed above, please explain here

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Anti-Fungal Medicines *

Please tick all that may apply. Comments are appreciated and helpful in diagnosis of disease

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

Oral anti-fungal medicnes?

Topical anti-fungals?

Not sure or other medicine, please explain

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Parasites *

Have you in the past 5 years been treated for or presently have parasites? Please check all that apply below. Please add when and how remedied. Example: I have been taking natural remedies for intestinal worms, mostly pomegranite.

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?
Do you live with dogs or cats?
Other parasite problems not listed here. Please explain
Never or none of these. Please explain

Treated for digetive 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?

Do you live with dogs or cats?

Other parasite problems not listed here. Please explain

Anything Else of Relevance *

Or other comments or requests. Please take your time here, and let us know more about you

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