Required fields are indicated by *

1. Surname *
2. First Name *
3. Email *
4. Street Address *
5. Postcode *
6. City *
7. Phone No. *
8. Date of Birth *
9. Gender *

   1. Male
   2. Female
10. Weight (kg) *
11. Height (cm) *

1. Do you have or have you ever had the following?

   1. Morbus Crohn
   2. Psoriasis
   3. Neurodermatitis
   4. Adipositas
   5. Migraine
   6. Multiple sclerosis
   7. Rheumatism
   8. Parkinson
   9. Chronic headache
   10. Fibromyalgia
   11. Acne
   12. Hypertension
   13. Diabetes
   14. Asthma
   15. Chronic Fatigue Syndrome
2. Please tick where applicable:

   These data are used for statistical purposes also and will be kept in confidence.

   Head

   1. Headache
   2. Dizziness

   Skin

   1. Redness
   2. Dry
   3. Itchy

   Gastro-intestine

   1. Sickness
   2. Feeling of fullness
   3. Flatulence
   4. Belching
   5. Diarrhoea
   6. Constipation
   7. Gastro-intestinal complaints
   8. Large waist

   Tongue

   1. Coated
   2. Ulcers
   3. Pustule
   4. Swollen
   5. Bleeding from the gums

   Heart

   1. Heart complaints
   2. Stabbing pain
   3. Palpitations
   4. Oppressive feeling

   Throat/lung

   1. Hoarseness
   2. Cough
   3. Breathing difficulties
   4. Congested with phlegm
   5. Sore throat

   Skeleton

   1. Backache
   2. Muscular pain
   3. Articular pain
   4. Arthrosis
   5. Numb sensation
   6. Swelling
   7. Stiffness
   8. Arthritis

   Psyche

   1. Exhaustion
   2. Mood swings
   3. Depression
   4. Hyperactivity
   5. Aggression
   6. Anxiety
   7. Lack of concentration
3. Do you take any medication at present?

   1. Yes
   2. No
4. Do you have a temperature or cold?
   (In case of a temperature an analysis is not possible!)

   1. Yes
   2. No
5. Do you have special eating habits?

   1. Often ready-to-serve
   2. Fast Food
   3. Often sweets

   Other, onesided eating habits:
   

6. Do you often have a ravenous appetite?

   1. Yes
   2. No
7. Do you have to follow a certain diet? (e.g. diabetes)

   1. Yes
   2. No

   If so, which one?
   

8. Have you been tested for foods in the past?

   1. Yes
   2. No

   If so, which ones and which test procedure was applied?
   

9. What kind of food do you mostly consume?

   1. Plain fare
   2. Vegetarian
   3. Wholefood
10. Do you know of any foods that cause you to have an allergic reaction?

    1. Yes
    2. No

    Please specify any known food allergies, and any foods avoided: