QUESTIONNAIRE

Fill out the online questionnaire at your leisure and make sure that all the information is correct. 

1 IDENTIFICATION NO.
2 QUESTIONNAIRE

PLEASE NOTE: Please use your Medicross order number as identification number.

In case you need to enter the information of an additional person in the online questionnaire or submission form for the same order, add “-2” to the identification number for an additional person, “-3” for the third person and so on. We ask you to carefully enter the mandatory data, because otherwise there may be delays in the process.

GENDER:
RECIPIENT OF THE RESULTS:

Please mark only applicable

1. rare 2. moderate 3. regular

 — FROM HERE ON, ALL INFORMATION IS VOLUNTARY –

LIFESTYLE
0123
Smoking
Endurance sports
Professional sport
Weight training
Vegan
Vegetarian
PREGNENT:

Please mark complaints by severity only
1. Slight/Rarely 2. Moderate/Moderately 3. Strong/Regularly

HEALTH PROBLEMS / DISEASES
0123
HEALTH PROBLEMS/DISEASES
Addictions
Aggression
Allergies
Arthritis
Arthrosis
Asthma
Candida
Cardiac/circulatory problems
Cholesterol problems
Constipation
Depression
Diabetes
Diarrhea
Eating disorders
Eczema, herpes
Exhaustion
Eye disease
Hair problems
Hearing problems
Hormonal problems
Hyperactivity
Hypertension
Infections
Inflammation
Intolerances
Joint diseases
Lack of drive
Memory disorders
Menstrual disorders
Mental illness
Metabolic diseases
Olfactory sense problems
Osteoporosis
Parkinson’s disease
Physical weakness
Poor adrenal gland function
Poor liver function
Prostate disease
Rheumatoid muscular complaints
Skin rashes
Sleep disorders
Stomach problems
Stress
Tasting problems
Teeth
Thyroid problems
Tinnitus
Wound healing disorder
MEDICATION:
YES NO
Mao inhibitor
Painkillers
Cortisone
Cardiovascular medication
Neuroleptics
Antibiotics
Hormones/contraceptive pill
Antidepressants
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