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Now You Can Fill your
Health Questionnaire

We need this information to set up the correct mix of pulsed magnetic field that will be best for your condition.

After we set up the optimum mix of programs we will send it to you as an mp3 attachment by email.

In case you have already filled in the groups 1 to 8 and the stress test, leave it blank.

Define Best Individualized Approach

Please note that all fields followed by an asterisk must be filled in.

First and Last Name*

How (name) should I address you?*

E-Mail Address*

Repeat E-mail Address *

Tick whenever you want to say "yes"

Group 1

	A Multiple pains
	B Fatigue
	C Family History of FMS

Group 2

	A Poor Sleep
	B Morning stiffness

Group 3

	A Chest problems
	B Abdomen problems
	C Pelvic problems(pain, bladder, sex, rectum)

Group 4

	A one joint pain
	B many joints pain

Group 5

	A Skin sensitivity
	B Acne, rosacea
	C Dermographism (can write on skin with finger)
	D Skin hyperhemia (skin gets suddenly bright red)

Group 6

	A Dizziness - Loosing balance
	B Feeling Very hot / Very cold
	C Foggy brain

Group 7

	A Poor circulation
	B Pins & needles
	C Numbness

Group 8

	A Headaches
	B Backpain

STRESS TEST

Rate the followings from 0 to 10
0=Not at all, 10=Always

Difficulties to sleep

Difficulties to think/concentrate

Getting quickly irritable/angry

Taking time to recover after a minor illness

Snacking often in between meals

Over-reacting

Shy away from social contacts

Neglecting your appearance

Feel misunderstood or unappreciated

Difficulties controlling your life

Feel lonely

Feel depressed

Feel tense/anxious

Feel frustrated/under pressure

Do you cry?

Started/increase smoking

Increase alcool consumption

Feel tired

Headaches or migraines

Missing work because overwhelmed

Negative thinking about work

Nail bitting

Overwhelmed with work/house/family chores

Lower self confidence/self esteem

Unable to do work/chores properly

DISABILITY RATING

Rate the followings from 0 to 10
0=Without difficulty, 10=Impossible

Dressing alone

Walking outdoor

Climbing stairs

Sitting longer time

Standing bent over a sink

Carrying a bag

Making a bed

Running

Light work

Heavy work

Lifting heavy objects

Exercises/Sports

HAVE YOU EVER HAD ANY

Liver problem

	YES
	NO

Kidney problem

	YES
	NO

Stomach/Gut problem

	YES
	NO

Heart problem

	YES
	NO

High Blood Pressure

	YES
	NO

Diabetes

	YES
	NO

Asthma

	YES
	NO

Osteoporosis

	YES
	NO

Neurological problem

	YES
	NO

Epilepsy

	YES
	NO

Could you be pregnant

	YES
	NO

Have you got a pacemaker/any other lectronic device

	YES
	NO

Have you had any brain surgery

	YES
	NO

Are you easily short of breath

	YES
	NO

Do you smoke

	YES
	NO

Do you drink alcohol

	YES
	NO

How old are you?

What's your height?

What's your weight?

Gender

	MALE
	FEMALE

Is your facial skin shiny?

	YES
	NO

Have you had pimples on your face

	YES
	NO

Does your face get easily red in the sun?

	YES
	NO

Does your face get dark spots in the sun?

	YES
	NO

Do you or your parents have wrinkles?

	YES
	NO

Please enter the word that you see below.

That's it. You will receive your mail with the appropriate mp3 within a week

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Now You Can Fill your Health Questionnaire

Define Best Individualized Approach

Now You Can Fill your
Health Questionnaire