Questionnaire - Patient new - Eng
Dear Patient,
Functional medicine is a systems biology-based approach that focuses on identifying and addressing the root cause of disease. Each symptom or differential diagnosis may be one of many contributing to an individual’s illness.
Thank you for taking the time to fill in this questionnaire so that I can help you the best I can.
It may take up to max 1H to complete.
In case you do not wish to fill in your details, you have that option. 
Please do fill in your correct email.
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PERSONAL INFORMATION
Date of today *
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Email *
Family & private name
Gender *
Required
Birth date *
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Adress
Phone number
Hight & Weight *
Do you have a family physician? If so, could you write the name?
 *
Are you seeing any other specialised doctor? If yes which? *
Women: last Gynecology visit? His name? Have you done tests (mammography, pap smear)?
Are you seeing any therapist for the moment (psychologist, reflexologist, acupuncture etc). If yes can you please specify who? *
How did you hear about the practice? *
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