Name *
Date of birth *
Telephone number *
E-Mail *
Profession *
Height *
Weight *
What do you like to eat and drink? *
How much do you drink per day, and what do you drink? *
Do you drink alcohol? If so, how much per day? *
Do you smoke? If so, how many per day? *
Do you exercise? If so, what sport do you do and how often? *
Do you have any hobbies? If so, which ones? *
Do you have enough free time for yourself? *
Do you experience stress? If so, what is causing it? *
Do you often feel tired? *
Do you feel tired when you wake up? *
Do you feel nervous or tense? *
Do you often feel moody or irritable? *
If you get angry, do you have enough self-control? *
Do you eat enough? *
Do you eat too much? *
Do you struggle with overweight? If so, do you know what causes it? *
Do you have a positive or negative self-image? *
Do you have enough self-confidence? *
Do you often take the initiative? *
Do you feel sad or worry about anything? If so, what is causing your worries and/or sadness? *
How many hours do you sleep per night? *
Do you consider that sufficient or insufficient? *
Do you suffer from nightmares? If so, can you describe what you dream about? *
Can you indicate whether your life feels meaningful to you? *
Have you ever considered suicide? *
How would you describe your current mental state? *
Do you have any physical complaints? *
Do you feel that your physical complaints are caused by stress or by external factors? *
Indicate the location of your complaints: (you can select multiple fields using the Ctrl key) *PsycheRespiratory systemDigestive systemMouth/throat/esophagusNose/earsUrinary tractSpine (neck/back/lower back)ShouldersBonesMusclesMenstruationCirculatory system and heartBowel problemsAllergies
For each of your current complaints, please indicate what might be causing them. *
For each of your complaints, please indicate whether you have consulted your general practitioner, and if so, what their diagnosis was. If not, please visit your GP first! *
Do you take any medication? *
If so, which medications do you take and how often? *
Are you currently under the care of a general practitioner or specialist? *
Have you ever had one or more hospital admissions? If so, for what reason? *
Are there any serious or chronic illnesses in your family? If so, which ones? *
Are you generally afraid of illness? *
How do you react to illness? Do you continue with your activities or take time to rest? What is your emotional state when you are ill? *
What is your temperament? Are you tearful, gentle, stern, cheerful, turbulent, enthusiastic, or perfectionistic? *
How easily do you adapt to a changed situation or a different environment? *
Any additional information
