Your name (required)
Your surname (required)
Your date of birth (mandatory)
Your place of residence (obligatory)
Your profession (mandatory)
Your e-mail address (required)
Names and dates of birth of your children (obligatory)
Your length in cm (mandatory)
Your weight in kg (mandatory)
Your ideal weight in kg (mandatory)
Movement/sports (obligatory)
Have you lived abroad or travelled outside the Netherlands? If so, when and where? (mandatory)
Have you experienced great losses in your life? If so, tell us about it briefly. (mandatory)
How much time have you had to take time off from work and your daily activities over the past year? (mandatory) 0 - 2 dagen3 - 14 dagenmeer dan 15 dagen
What are your biggest concerns about your health? Describe your concerns in as much detail as possible, including how you experience the symptoms. (mandatory)
When did the complaints start? (mandatory)
What have you done in the past to reduce your complaints? (mandatory) HuisartsZelfzorgAlternatieve GeneeskundeNietsAnders
Have you seen any improvement with this approach? (mandatory)
Which other therapists or therapists do you work with at the moment? Name the name and expertise. (mandatory)
Please include the date and description of any surgical procedures you have undergone, including cosmetic procedures and Caesarean section (mandatory).
How often did you take antibiotics in childhood? (mandatory)
How often did you take antibiotics in your teenage years? (mandatory)
How often did you take antibiotics as an adult? (mandatory)
What medicines are you taking at the moment? (mandatory)
Name the vitamins, minerals, herbs and other nutritional supplements you are currently taking: (mandatory)
Do you have family members who have the same or similar complaints? (mandatory)
Are there foods that you avoid because you react to them? If so, what is your diet and how do you react to it? (mandatory)
If you have symptoms immediately after eating such as bloating, flatulence, sneezing or rashes / itching, explain: (mandatory)
Are you aware of complaints that occur later after eating certain foods such as fatigue, muscle aches, blocked nose etc.? If so, explain: (mandatory)
Are there foods that you cannot leave behind? If so, which? (mandatory)
Describe your diet when the symptoms started. (mandatory)
Do you have food allergies or hypersensitivity? (mandatory)
Which foods do you eat often? (mandatory) FrisdrankSuikervrije frisdrankGeraffineerde suikerAlcoholFastfoodGlutenZuivelKoffieGeen van de bovengenoemde
Are you currently following a certain diet? (mandatory) PaleoGAPSLactose-vrijVegetarischVeganBloed typeRauwSuikervrijGlutenvrijAnders
What percentage of your evening meals are prepared at home? (mandatory) 0 - 15%15 - 30%30 - 45%45 - 60%75 - 90%meer dan 90%
Are there any other important things to report about your diet, past or relationship with nutrition? (mandatory)
How often do you have a bowel movement? (mandatory) 1 - 3 maal per dagmeer dan 3 maal per dagniet regelmatigminder dan eenmaal per dag
Consistency of the stool, several answers are possible (mandatory) Zacht & goed gevormdVaak drijft hetMoeilijk te eliminerenDiarreeWaterigLang en dunSmal en hardNiet waterig maar wel heel zachtSoms hard en soms zachtWisselende ontlasting
Colour of the stool, several answers are possible (mandatory) BruinHeel donker of zwartGroenigIk zie bloed erinVeranderlijkGeelLicht bruinLichte kleur (kalk)VettigGlimmend
Do you suffer from flatulence? If so, explain if it is a lot, occasionally comes up, smells etc: (mandatory)
Tick what is applicable to you with regard to your health: (mandatory) KankerHart- en vaatziekteHepatitisGeslachtsziekteDiabetesHoge bloeddrukHoge cholesterolNier ziekteSchildklier probleemDepressieAstmaAllergieënBloedarmoedeChronische schimmelinfectiesHersenschudding of hoofd letselEet stoornisAnders
Briefly describe the symptoms, the chosen treatment(s) and the period in which you have suffered from the abovementioned syndrome(s): (obligatory)
Do you ever experience the following, several answers are possible: (mandatory) Korte termijn geheugenverliesVerminderde focus of concentratieCoördinatie en evenwicht problemenProblemen met een verlies van controle (geen remming)Niet kunnen organiserenMoeite met plannen (altijd te laat of het vergeten van afspraken)StemmingswisselingenMoeite om woorden te vinden en je verhaal te vertellenWazig hoofdMinder effectief en productief thuis/op school/op het werkMinder verantwoord bijv. het vergeten de oven uit te zetten
Are you exposed to chemicals or heavy metals such as lead, mercury, arsenic or aluminium? (mandatory)
Do you suffer from smells? (mandatory)
Are you many exposed to passive smoking? (mandatory)
How long has it been since you last went to the dentist? What was the reason for your visit? (mandatory)
Has a dentist or oral hygienist talked about your oral hygiene, blood sugar or other health concerns in the past year? If yes, please note (mandatory)
What is your routine for keeping your teeth and mouth clean? Describe how many times a day you pay attention to this and what type of toothpaste you use (mandatory)
Do you have amalgam fillings? If not, have they been removed and how? (mandatory)
Are there any concerns you have about the health of your teeth and/or mouth? (mandatory)
Is there anything else you would like to share about your teeth or oral hygiene? (mandatory)
Have you had periods in which you ate a lot of junk food, followed a lot of diets or ate too much (binge eating)? Please list the diets you have followed and how long you have kept them. (mandatory)
Have you ever been addicted to alcohol, drugs, medication, nicotine/tobacco or caffeine? Is that still the case? (mandatory)
How do you deal with stress? (mandatory)
Are you satisfied with how you sleep? (mandatory)
Are you awake all day without dozing off? (mandatory)
Are you awake (or trying to get back to sleep) between 2 and 4 a.m.? (mandatory)
Do you fall asleep in less than 30 minutes? (mandatory)
Do you sleep between 6 and 8 hours a night? (mandatory)
How old were you when you first started menstruating? (mandatory)
How is/are your period? Did you or did you suffer from PMS? Do you or did you have painful periods? If so, explain? (mandatory)
In the second part of your cycle do you experience sensitive breasts, moisture retention, having a short fuse? (mandatory)
Have you ever had fungal infections or cystitis? How often do they occur? (mandatory)
Did you take or did you take the pill? If so, how long? (mandatory)
Have you ever had problems getting pregnant? (mandatory)
Do you take hormone supportive herbs or do you follow other hormone therapies? If so, name them below: (mandatory)
Are there any concerns you want to share about your sexual functioning such as pain during sex, vaginal dryness, libido problems etc.? (mandatory)
How is your mood in general? Do you suffer from anxiety, depression or anger and are these emotions more intense than you would like? (mandatory)
On a scale of 1-10, where 1 is the worst and 10 is the best, describe your energy level: (mandatory)
When did you feel your best? Why? (mandatory)
Do you think your family and friends will support you in making healthy changes to improve the quality of your life? If not, explain. (mandatory)
Describe any other information you think could be useful in treating your health problems. (mandatory)
What are your health goals and ambitions? (mandatory)
Even if it seems like a strange question, why do you want to achieve this for yourself? (mandatory)
