Questionnaire on Medical History

Dear Patient,

The information about yourself and your medical history in this patient questionnaire serves to clarify your disease or symptom profile. Our doctors and team of medical professionals will use this information to prepare for your arrival and provide the best treatment for your situation. Complete to the best of your ability, and we assure it will be in your best interest.

Please fill out the boxes accordingly. Your answers are subject to medical confidentiality. Thank you for your cooperation!

 day patient stationary

 as soon as possible (immediately) desired date

Digestive Symptoms

 normal form watery mushy very firm

 not often frequently middle

Drinking Behavior

 Yes No

 Yes No

 Liver Cleanse Heavy Metal Detox Health Check Intensive 21-day Individual Program Other

 No Yes, 1 page Yes, 2 pages Yes, 3 pages

 Recommendation Internet Advertising Other

Download a PDF Version of the Questionnaire here:

Medical History Questionnaire

Email the completed questionnaire to