Name* First Last Address Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* PhoneDate of birth* Date Format: MM slash DD slash YYYY Section 1Do you have a heart pacemaker?*YesNoNot applicableDo you have a hearing aid?*YesNoNot applicableAny metal implants?*YesNoNot applicableFor women - are you pregnant?*YesNoNot applicableHave you had a transplant?*YesNoNot applicableWhat is your reason for seeking bioresonance?*When did this first begin?What was the initial cause?What makes it worse?What makes it better?This problem affects your?* physical well-being emotional well-being mental well-being walking standing sitting lying down sleep work life exercise social life personal relationships sexual life How are your energy levels?GreatOkayFluctuatingPoorWhat's energy?Do you have a high point during the day?YesNoDo you have a low point during the day?*YesNoDo you sleep well?*YesNoDo you drink tea or coffee?*YesNoDo you drink alcohol?*YesNoDo you smoke?*YesNoSigns / SymptomsGeneral problems, tick all that apply: Fatigue lack of energy sudden energy drops shortness of breath poor sleep insomnia nightmares night sweats snoring travel sickness unusual perspiration no perspiration at all sweat easily hair loss unintended weight loss unintended weight gain overweight underweight fluid retention heavy drinking smoking sugar cravings sugar causing neg symptoms poor appetite always hungry always thirsty peculiar tastes excessive phlegm tumours cancer none of the above Immune system, tick if you have ever had any of the following rheumatic diseases arthritis fibromyalgia chronic fatigue frequent colds ulcerative colitis morbus crohn coeliac disease hay fever chronic low grade fever swollen glands/lymph nodes measles mumps chicken pox shingles scarlet fever multiple sclerosis chronic fatigue syndrome syphilis gonorrhoea herpes HIV/AIDS none of the above Digestive system, tick if you have had any of these constipation diarrhoea dark stools very smelly stools blood in stools mucous on/in stools irritable bowel syndrome intestinal cramping loss of appetite bloating gas belching tiredness after eating no appetite in the morning hiccups, abdominal cramping / pain food allergies or intolerances abdominal distension heartburn acid regurgitation vomiting stomach or duodenal ulcers gastritis lack of stomach acid pancreatitis gallstones hepatitis liver cirrhosis gallbladder disease laxative use haemorrhoids none of the above Head, tick all that you suffer from or have suffered from* headaches migraines dizziness / vertigo concussion loss of hair premature greying of hair none of the above Mental / emotional / nervous system, tick all that you suffer from or have suffered from* moodiness irritability excessive worrying poor memory dyslexia anxiety fearfulness phobias nervousness poor concentration stuttering confusion depression short temper outbreaks of rage seizures epilepsy bipolar disorder OCD ADD ADHD drug addiction alcoholism abuse survivor none of the above Mouth, tick which apply* dry mouth / throat metallic / bitter / sour / foul taste in mouth halitosis (bad breath) bad teeth bleeding gums abscesses mouth ulcers inflammations cold sores jaw joint pain cracking jaw joint grinding teeth missing teeth root canal amalgam / gold fillings crowns inlays bridges false teeth braces none of the above Ears, tick which apply* poor hearing deafness tinnitus (ringing in ear) itching of ear canal frequent ear infections ear aches none of the above Nose, tick which apply* poor sense of smell congested nose runny nose / clear discharge yellow/green phlegm recurring sinus infections polyps post nasal drip nose bleeds cold sores none of the above Eyes and Vision, tick which apply* poor vision blurred vision dry eyes itchy eyes red eyes floating spots in vision wind sensitivity light sensitivity cataracts none of the above Skin, tick which apply* eczema acne (pimples) dry skin oily skin itchy skin neurodermatitis psoriasis warts abscesses rash fungal infection athlete’s foot nail infection none of the above Respiratory system, tick which apply* cough shortness of breath asthma wheezing bronchitis pneumonia frequent colds frequent tonsillitis / sore throat / strep throat emphysema lung abscesses tuberculosis whooping cough coughing blood none of the above Urinary system, tick which apply* UTIs (urinary tract infections) kidney stones incontinence pain when urinating difficulty urinating blood in urine too frequent urgent urination wake at night to urinate urinary reflux bladder weakness none of the above Heart and circulation, tick which apply* fast pulse (resting pulse rate over 100 bpm) slow pulse (less than 60 bpm) palpitations heart arrhythmia chest pain or tightness high blood pressure low blood pressure stroke constantly feeling hot constantly feeling cold cold hands cold feet burning hands burning feet afternoon/evening fevers constant low-grade fever blushing hot flushes anaemia dizziness when standing up fainting spells bruise easily numbness or tingling sensations none of the above Hormone system* diabetes low blood sugar level enlarged thyroid hypothyroidism none of the above I am femaleYesNoMuscles, joints and bones injuries to joints injuries to bones injuries to muscles injuries to ligaments or sinews injuries to tailbone injuries to spine injuries to neck injuries to skull pain in joints pain in bones pain in muscles pain in ligaments or sinews pain in tailbone pain in spine pain in neck pain in skull muscle cramps limited range of motion tight neck/shoulders lower back pain lumbar prolapse / herniated disc sciatica, weak legs leg length difference RSI/OOS none of above The following things can affect one’s health, even long after they are over, list which applyPlease tick which apply in the past or now1. Any pregnancy or birth complications (ask your mother if possible)*YesNo2. Issues that affect the whole family: Absence or illness of family members, addictions of any kind,psychological illness, (attempted) suicide, physical, sexual or emotional abuse, emotional neglect, etc.*YesNo3. Unusual course of children’s diseases and complications from vaccinations*YesNo4. Any serious or recurring disease?*YesNo5. Psychological issues, traumatic or unsettling experiences*YesNo6. Accidents (including sports accidents)*YesNo7. Surgeries and other invasive procedures*YesNo8. Recreational drug use (past or present)*YesNoYour close family’s medical history: Please indicate if any of your family members have or had any of the following conditions:Allergies*YesNoI don't knowHeart Disease*YesNoI don't knowArthritis*YesNoI don't knowChronic fatigue diabetes*YesNoI don't knowParasites*YesNoI don't knowTuberculosis*YesNoI don't knowHepatitis*YesNoI don't knowCancer*YesNoI don't knowHypo/hyperthyroid*YesNoI don't knowEpilepsy*YesNoI don't knowSeizures*YesNoI don't knowAdditional Comments:
