Deep Dive Parasites - BSI Survey

Deep Dive Parasites and Diseases
Testing and Remedies Service

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We request all patients complete Deep Dive Patient Questionnaire. Your detailed history will greatly help us to help you.

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

Part One : Getting to Know You ...

Patient Full Name *

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

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.

Phone and / or W/A *

Please enter correct phone number(s) so we may contact you in the event of schedule changes, important questions, etc. We respect your privacy.

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
Ubud / Sanggingan, Doctor Steven
GWK / Jimbaran, Doctor Igo

Membership *

I have previously taken the BSI Signature Evidence-Based Diagnostics with Holistic Detox & Therapies Program, when and where
I have never taken the BSI Signature Evidence-Based Diagnostics with Holistic Detox & Therapies Program

When and where *

We request all new members to complete the BSI Signature Evidence-Based Diagnostics with Holistic Detox & Therapies Program, either before or during the Signature Course. Please click here to open the Signature Course Questionnaire.

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

Deep Dive Parasites and Diseases Testing and Remedies Service - Rp. 5,500,000

Optional test

BSI Signature Holistic Health Reset & Detox, Members Re-testing & Diagnosis With Natural Therapies - Rp. 2,760,000

BSI Signature Holistic Health Reset & Detox, Testing & Diagnosis With Natural Therapies - Rp. 4,300,000

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Total

Rp. 0

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Nationality *

Legal citizen of what nation

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

Referred by Whom *

Really helpful to us, thanks !

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.

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

Patient Gender *

Biological gender is needed for accuracy in blood testing

Biological male
Biological female
Different options

Present Age in Years *

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

Date of Birth (m/d/y) *

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

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

Please comment

Part Three : Patient Request for Services ...

Please Fully Describe the Illness or Concerns *

Example: I have constant bloating and often dizzy. I have red raised lines on my skin. My scalp itches all the time. My bum itches and is sore.

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, 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.
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

Skin and Scalp *

I have acne (please describe where and severity)
Moles or skin growths (please describel in detail)
Reddish lines or unusual veins visble on my skin
I have been biten by flies, spiders, ticks, snakes or other biting animals (describe when and where and reactions)
Dandruff or a scalp condition (please describe)
Excessive hair loss
Dry or flaky skin
My skin is very oily
Excessive body odor
Psoriasis or a similar condition
Other condiion not listed

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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
Lines or long objects on the surface of the eye
Itchy or mucous excretions from eye lashes
White or clearish discolorations of the eye
Blindess in 1 or both eyes
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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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 disease
Other not listed here. Please explain
Never or not sure

Please enter your comment

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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 on none of the above

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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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
None of these

Please enter your comment here

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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? *

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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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

Please enter your comment here

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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

Please enter your comment here

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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

Please enter your comment here

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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

Please enter your comment here

Deep Dive Parasites and DiseasesTesting and Remedies Service

Part One : Getting to Know You ...

Part Two : Patient Vital Information ...

Part Three : Patient Request for Services ...

Part Four : General Health Questions ...

Deep Dive Parasites and Diseases
Testing and Remedies Service