Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

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Allergies *

No allergies

Milk products

Gluten

Eggs

Fish

Strawberries

Kiwi

Raspberries

Animals

Cats

Dust

I often sneeze

I often have red eyes

I often have sinus infections

I often have throat pain

I have asthma

I have migrains

I have headaches

I have ezcema

I have dermatitis

I have redness

I have dark underyes

Bees

Wasps

My face is swollen in the morning

My eyelids are swollen in the mornin

I ended up in ER because of my allergy

I had angioedema

Peanuts

All nuts

I often have stuffed nose

Ambrosia

House dust mites

I often have watery eyes

Antibiotic

Penicilin

Skin *

Dry

Normal

Oily

Combination

Dehydrated

Hormonala acne

Blackheads

Whiteheads

Cystic Acne

Hypopigmentation

Hyperpigmentation

Vitiligo

Rashes

Psoriasis

Redness

Skin flaking

I often have oral herpes (cold sores)

I have many moles

I never had herpes

I have acne scars

I have other scars

I have saggy skin

I have enlarged pores

I have lot of wrinkles

I have eye wrinkles

I have wrinkles above my lips

I have stretchmarks

I have keloid scars

I have cellulite

I have lymphedema

I have visible capillaries on my face

I have visible capillaries on my body

I have itchy skin

I have spider veins

I have scleroderma

I have lupus

I have rosacea

I have uneven skintone

I have pimples before my cycle

I have new pimples every day

I have new pimples every week

I have new pimples monthly

I never had oral herpes (cold sores)

I have increased hair on my body

Hair *

Thin

I am loosing a lot of hair

I do not have hair

I have alopecia

I have hair transplant

My hair is healthy

My hair is oily

My hair is dry

My hair breaks easily

I dye my hair

Drugs *

Controloc

Nexium

Cardiopirin

Aspirine

Besedine

Propranolol

Lorazepam

Famotidine

Eutyrox

Fraxiparin

Prednisone

Pronisone

Epica

Roxera

Pregabalin

Lasix

Canabis

Roaccutan

Brilique

Heferol

Clindasome

Nitroglycerine

Cycle *

I have regular cycle

I have irregular cycle

I do not have cycle

My cycle lasts more than 7days

My cycle lasts less than 5 days

I have premenstrual pain

I have premenstrual depression

I have menstrual pain

I have ovulation pain

I have visited gynaecologist in the past 12 months for ultrasound

I have done breast ultrasound in the past 12 months

I have cyclic breast pain

I am in postmenopause

I am a man

Digestive issues *

Gas

Bloating

Weight gain

Weight loss

Bulimia

Anorexia

Orthorexia

Stomach pain

Constipation

Diarrhea

Stress

Lack of sleep

Sitting more than 7 hours per day

Burping

Difficulty swallowing

Cavity/Caries/Tooth decay

I have 1 meal per day

I have 2 meals per day

I have 3 meals per day

I have 4 meals per day

I have 5 or more meals per day

I eat almost whole day

I eat after 8pm

I eat after 10pm

I eat as soon as I get up

I drink 1l of water per day

I drink 1.5l of water per day

I drink 2l of water per day

I drink more than 2.5l water per day

I drink soda

I drink fruit juices

I drink energy drinks

I eat sweets every day

I lay in bed after 10pm

I lay in bed after 12pm

I get up before 8am

I get up after 8 am

I drink tea every day