TRUE Health Questionnaire
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All data is handled accordingly to GDPR policy.
Name
Your answer
Date of birth
MM
/
DD
/
YYYY
Address:
Your answer
Mail address:
Your answer
Length:
Your answer
Weight:
Your answer
Proffession:
Your answer
Marital Status:
Your answer
Number of kids:
Your answer
Genetic Background
Blood Type:
Do you have allergies? If so what kind.
Your answer
Do you take any over the counter medications:
Your answer
What is the reason for this health consultation?
Your answer
Do you have symptoms, if so when did they start?
Your answer
Does your pain or symptom remain the same no matter what you do?
Your answer
Have you sought medical help for this symptom before?
If YES - what treatment was recommended and has helped you?
Your answer
What time during the day is the symptom the worst?
Morning
Night
Have you ever experienced:
Ja
Nej
High blood pressure
Heart problem / failure
Circulatory Problems
Ulcer
Diabetes
Insulin resistent
Migraine
Muscular pain
Genetic Disease
Lowered eyesight
Other
Has anyone in your family had a serious illness like cancer or other life-threatening disease? If yes please explain.
Your answer
Have you ever had surgery? If yes - what kind and what was the outcome?
Your answer
Do you have metal anywhere in your body?
Your answer
Do you experience any of the symptoms daily?
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