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Diagnostisch formulier
Name
*
Last name
*
E-mail
*
Phone
*
Age
Height
Weight
Height
Age
Weight
Are you on any medication?
Are you on any medication?
Are you allergic to anything?
Are you allergic to anything?
Describe your problem
*
Attach a photo of your tongue
De maximale bestandsgrootte is %size% MB.
Diagnostic questionnaire - here you can specify what is bothering you
Is your hair falling out?
no answer
never
occasionally
often
Still
Are your nails breaking?
no answer
never
occasionally
often
Still
Do you have dry skin?
no answer
never
occasionally
often
Still
Are you cold-hearted?
no answer
never
occasionally
often
Still
Are you hot-blooded?
no answer
never
occasionally
often
Still
Do you have flushes?
no answer
never
occasionally
often
Still
Are you experiencing any hot flashes?
no answer
never
occasionally
often
Still
Do you ever get a headache?
no answer
never
occasionally
often
Still
Do you suffer from cold sores?
no answer
never
occasionally
often
Still
Do you ever get dizzy?
no answer
never
occasionally
often
Still
Do you have high blood pressure?
no answer
never
occasionally
often
Still
Do you have low blood pressure?
no answer
never
occasionally
often
Still
Do you suffer from shortness of breath?
no answer
never
occasionally
often
Still
Do you get forgetful?
no answer
never
occasionally
often
Still
Do you ever cough?
no answer
never
occasionally
often
Still
Do you ever notice a heartbeat?
no answer
never
occasionally
often
Still
Are you having cramps?
no answer
never
occasionally
often
Still
Do you have a lump in your throat?
no answer
never
occasionally
often
Still
Do you suffer from recurrent sore throat?
no answer
never
occasionally
often
Still
Do you suffer from bloating?
no answer
never
occasionally
often
Still
Do you get tired after eating?
no answer
never
occasionally
often
Still
Do you have heartburn?
no answer
never
occasionally
often
Still
Do you have reflux?
no answer
never
occasionally
often
Still
Do you have a dry mouth?
no answer
never
occasionally
often
Still
Do you have dry lips?
no answer
never
occasionally
often
Still
Do you eat regularly?
no answer
never
occasionally
often
Still
Is the stool regular?
no answer
never
occasionally
often
Still
Is the stool soft and mushy?
no answer
never
occasionally
often
Still
Is the stool dry?
no answer
never
occasionally
often
Still
Is there a problem with stool expulsion?
no answer
never
occasionally
often
Still
Do you suffer from bladder inflammation?
no answer
never
occasionally
often
Still
Do you urinate too often?
no answer
never
occasionally
often
Still
Do you wake up to urinate during the night?
no answer
never
occasionally
often
Still
Are you tired?
no answer
never
occasionally
often
Still
Are you falling asleep well?
no answer
never
occasionally
often
Still
Do you wake up during the night or early in the morning?
no answer
never
occasionally
often
Still
Do you have dry or tired eyes?
no answer
never
occasionally
often
Still
Do you have tinnitus or ringing in your ears?
no answer
never
occasionally
often
Still
Do you have swelling?
no answer
never
occasionally
often
Still
Do you have regular periods?
no answer
never
occasionally
often
Still
Do you have a shorter cycle?
no answer
never
occasionally
often
Still
Do you have a longer cycle?
no answer
never
occasionally
often
Still
Do you have heavy menstruation?
no answer
never
occasionally
often
Still
Do you have weak menstruation?
no answer
never
occasionally
often
Still
Do you have pain before your period?
no answer
never
occasionally
often
Still
Do you suffer from premenstrual syndrome?
no answer
never
occasionally
often
Still
Are there gynecological discharges?
no answer
never
occasionally
often
Still
Do you have anxiety, depression, fears?
no answer
never
occasionally
often
Still
You gonna blow up easy?
no answer
never
occasionally
often
Still
Are you suppressing your emotions?
no answer
never
occasionally
often
Still
Vaccination for covid
no answer
Yes
No
Do you have an aversion to sex?
no answer
never
occasionally
often
Still
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