Disease Information Form

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Disease Information Form

Please fill out the form and we will help you heal.

Informatie Form

Name:

Gender

Man

Vrouw

E-mail:

Phone:

B. Date :

Tall

Kg:

Bloodgroup:

Your Disorders:

Kanker / Cancer

Diabetes / Diabet

Hart / Heart

Bloeddruk / Bloodpressure

Alzheimer

Parkinson

Eczeem

Psoriasis

Lever / Liver

Nier / Kidney

Reuma

Schildklier / Thyroid

Paniek Aanval / Panic Attack

Verlamming / Paralysis

Lyme

Hepatiti

Vitiligo

Autisme

Andere psychische stoornissen / Andere psychische stoornissen

Andere auto-immuunziekten / Other autoimmune diseases

Medicines you are taking:

Pijnremmer

Onstekingremmer

Immuneremmer

Antibiotica

Chemothrapie

İnsulin

Bloeddruk

Hormon Balance medicijnen

Kruidensupplementen

Vitaminen

Homeopathie

Anders

Your story

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