GENERAL QUESTIONNAIRE (PAGE 1/ 7)

PATIENT PHYSICIAN

Last name Last name

First name First name

Gender Female Male Street, No.

Date of birth Postcode, City

Social Security Nr. Country

Street, No. Tel.

Postcode, City Email

Country
IMPORTANT NOTE:
Tel. Please fill in all the fields in capital letters. All information is
provided voluntarily.
Email

Personal profile Antiplatelet drugs never sometimes Dietary supplements

Age years regularly Vitamin B yes no
Gender f m Acetylsalicylic acid complex
Ethnic Caucasian Clopidogrel B3 B6 B12
Asian B9 (folic acid)
African Anticoagulants yes no Vitamin C yes no
Coumarin derivatives Vitamin D yes no
Height cm Heparin Vitamin E yes no
Weight kg Omega-3 fatty acids yes no
Blood group 0 A B AB Analgesics (painkillers) never sometimes Calcium yes no

Life style regularly Magnesium yes no

Smoker yes no Paracetamol Iron yes no
ex-smoker since Ibuprofen Selenium yes no

How many cigarettes, cigars, 1-5 6 - 10 Zinc yes no

pipes, etc. do you smoke per day? 11 - 20 > 20 Glucocorticoids yes no Other
Physical activity yes no Cortisone About your nutrition
(at least 30 min) daily 1x/week Food intolerance(s) yes no
2x/week 3-6x/week Antidepressants yes no Gluten Fructose
endurance sports (jogging, biking, etc.) Barbiturates never sometimes Lactose
power training (weight lifting, etc.) regularly
mind-body sports (Pilates, Yoga, Tai Chi, etc.) Anticonvulsants never sometimes Food allergy yes no
others (antiepileptic drugs) regularly Tree nuts Fish

Frequent prolonged yes no Valproic acid Peanuts Soy

immobility (sedentary work/lifestyle, long flights/car rides) Carboxamides Shellfish
Stress never sometimes Benzodiazepine Eggs
regularly Milk

Current medication Hormone replacement therapy yes no

Statins yes no Estrogens Vegetarian yes no
Other lipid-lowering drugs yes no Gestagen Vegan yes no

Antihypertensives yes no Testosterone levele

ACE inhibitor < 5 years > 5 years
Barcode:
Beta blocker Oral contraception yes no
Calcium channel blocker discontinued
long term
Diuretics yes no Other drugs
Loop diuretic
Thiazide diuretic

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GENERAL QUESTIONNAIRE (PAGE 2/ 7)
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PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Drinks Apiaceae (e.g. carrots, fennel, celery) Shellfish yes no

Red wine yes no (z, Garnelen, Krabben, Hummer, etc.)
Carbs with high
1-2 glasses/day glycemic index (GI) yes no Omega-3 fatty acids yes no
> 2 glasses/day (e.g. white bread/pasta/rice, (e.g. in salmon, herring, linseed oil, Chia seeds, etc.)
sugar, sweets, etc.)
Other/additional alcohol yes no Saturated animal fats yes no
1-2 glasses/day (e.g. in butter, cheese, cream, bacon, etc.)
Carbs with low
> 2 glasses/day glycemic index (GI) yes no Vegetable oils yes no
Coffee yes no (e.g. legumes, whole grain products, etc.) (e.g. olive oil, linseed oil, rapeseed oil, etc.)

1-3 cups/day Dietary fibres yes no Salt rich products yes no

> 3 cups/day (e.g. in legumes, whole grain products, fruits, vegetables, etc.) (e.g. crisps, pickles, anchovies, cured meat, etc.)

Tea (white, black or green tea) yes no Dairy products yes no Spicy dishes no
1-2 cups/day (e.g. milk, yoghurt, curd cheese, etc.) (e.g. with turmeric, cardamom, chili, cinnamon, etc.)

> 2 cups/day Calcium-rich products yes no

Raw sugar, honey,
(e.g. dairy products, sardines, green vegetables, etc.) yes no
Energy drinks yes no maple syrup, sweets, etc.
(rich in caffeine (Guarana), taurine. etc., e.g. Red Bull) (check only if consumed in
Soy products yes no
notable quantities)
(e.g. tofu, tempeh, soy milk, soy beans, etc.)
Soften drinks yes no
(containing phosphoric acid, etc., e.g. Cola, sodas) yes no
Red meat Deep-fried food yes no
Daily fluid intake ≤ 1 Liter 2 Liter (e.g. beef, pork, lamb, duck, 1 - 2 x per week (e.g. French fries, potato chips, fried chicken, doughnuts, etc.)
game, horse, etc.)
≥ 3 Liter 3 - 4 x per week Grilled/smoked food yes no
Regular consumption ≥ 5 x per week (e.g. barbecued meat or fish, etc.)

Fruits and vegetables yes no White meat yes no “light” products yes no
Tomatoes (e.g. chicken, turkey, rabbit, veal, etc.) (fat or sugar reduced food)

Green leafy vegetables (e.g. spinach, chard, lettuce) Fish yes no Convenevernce food/fast food yes no
Cruciferae (e.g. broccoli, Brussels sprouts) Cold water fish (e.g. salmon, mackerel, etc.)

SPECIFIC QUESTIONNAIRES
Vertigo never sometimes Other disease(s)/disorder(s):

CARDIOgen Red, flushed face

regularly

yes no

Headaches in the morning never sometimes Your family medical history*

LDL level mg/dl regularly
please do only consider first and second degree relatives
*

HDL level mg/dl Nosebleed never sometimes (i.e. grandparents, parents, siblings, children, aunts, uncles,
regularly neverces, nephews, grandchildren)
Total cholesterol mg/dl
Triglycerides mg/dl Your medical history Diabetes yes no

Systolic/diastolic blood mmHg Diabetes yes no Hypertension yes no

pressure (ex: 120/80 mmHg) Type 1 Type 2 Cardiovascular disease yes no
Fasting plasma glucose mg/dl Hypertension yes no myocardial infarction

Swollen legs or ankles never sometimes Cardiovascular disease yes no

regularly myocardial infarction Thrombosis yes no

Tension or pain in legs/calves never sometimes

regularly Cardiac insufficiency yes no
Barcode:
Pain in feet or legs while never sometimes Hyperlipidaemia yes no
walking or standing regularly Obesity yes no
Varicose veins yes no Thrombosis yes no

Lesions on ankles/lower legs yes no Oedema yes no

that do not heal Kidney disease yes no

Dyspnoeic if physically stressed never sometimes

regularly

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SPECIFIC QUESTIONNAIRES (PAGE 3/ 7)
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PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Cancer yes no Your family medical history*

COLOgen Liver
Lung
Bladder
Kidney
please do only consider first and second degree relatives
*

(i.e. grandparents, parents, siblings, children, aunts, uncles,

neverces, nephews, grandchildren)
Colon Breast

Your medical history Leukaemia Colon cancer yes no

Digestive problems yes no Stomach Number of affected 1 person
Inflammatory bowel disease yes no Skin family members? > 1 person

Crohn’s disease
Ulcerative colitis Other disease(s)/disorder(s):
Intestinal polyps yes no
DIABETOgen
Paints, solvents, glues yes no Waist circumference cm

DETOXgen Epoxy resins

(e.g. epoxy glues, etc.)
yes no
(measured at the navel)

Fasting plasma glucose mg/dl

Pesticides: insecticides, yes no Fasting insulin level mg/dl

herbicides, etc. HbA1c %
Agitation, hyperactivity never sometimes
regularly Polychlorinated biphenyls (PCBs) yes no Your medical history
(e.g. as plasticizers in paints/ Obesity yes no
Anxiety never sometimes
cements, in PVC coatings, etc.)
regularly Diabetes yes no
Lack of energy, fatigue yes no Car exhaust fumes yes no Type 1 Type 2
(working/living in the city) Cardiovascular disease yes no
Mood disorders yes no
(e.g. mood changes, depression, etc.) Hair dyes yes no myocardial infarction

Headaches never sometimes Your medical history

regularly Digestive problems yes no Thyroid disease yes no

Dizziness never sometimes Kidney disease yes no hypofunction

regularly Liver disease yes no hyperfunction

Absence of appetite never sometimes Skin disease yes no

regularly which? Cancer yes no

Metal taste in the mouth never sometimes Inflammatory disease yes no Liver Bladder
regularly which? Lung Kidney

Infections in the mouth never sometimes Allergies yes no Colon Breast

regularly which? Leukaemia
Prickling in hands/feed never sometimes Cancer yes no Stomach
regularly Liver Bladder Skin

Joint and muscle pain never sometimes Lung Kidney

regularly Colon Breast Other disease(s)/disorder(s):

Agitated sleep, insomnia never sometimes Leukaemia

regularly Stomach

Attention deficit disorder/ never sometimes Skin

memory troubles regularly
Barcode:
Circulatory disturbances never sometimes Alopecia (hair loss) yes no
regularly Anaemia yes no
Susceptible for infects yes no Arthritis yes no

Environmental exposure Other disease(s)/disorder(s):

Dental amalgam yes no

Heavy metals yes no

(e.g. cadmium, lead, mercury, etc.)

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SPECIFIC QUESTIONNAIRES (PAGE 4/ 7)
®

PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Your family medical history* Benign breast disease yes no

please do only consider first and second degree relatives

*

(i.e. grandparents, parents, siblings, children, aunts, uncles,

FEMgen premenopausal
postmenopausal
neverces, nephews, grandchildren)
Atypical hyperplasia yes no
Obesity yes no Gynaecological history premenopausal

Diabetes yes no First menstrual cycle (menarche) < 13 years >13 years postmenopausal
Type 1 Type 2 Menopause yes no Cancer yes no
Cancer yes no < 54 years > 54 years Liver Bladder
Pregnancy yes no Lung Kidney
< 30 years at first childbirth Colon Breast

FITgen > 30 years at first childbirth Leukaemia

Stomach
Breastfeeding yes no
< 1 years > 1 years Skin

Waist circumference cm High mammographic yes no

(measured at the navel) breast density (≥ 75%)
Other disease(s)/disorder(s):
Systolic/diastolic blood mmHg Your medical history
pressure (ex: 120/80 mmHg)
Obesity yes no
Lack of energy, fatigue yes no prämenopausal Your family medical history*
Your medical history postmenopausal
please do only consider first and second degree relatives
*

Migraines yes no Diabetes yes no (i.e. grandparents, parents, siblings, children, aunts, uncles,
neverces, nephews, grandchildren)
Digestive problems yes no Type 1 Type 2

Inflammatory disease yes no Cardiovascular disease yes no Breast cancer yes no

which? myocardial infarction Number of affected 1 Person
family members? > 1 Person
Allergies yes no
which? Thyroid disease yes no Current Medication
Cardiovascular disease yes no Unterfunktion Tamoxifen yes no
myocardial infarction Überfunktion Raloxifen yes no
Aromatase inhibitors yes no
Hypertension yes no
Hyperlipidaemia yes no Kidney disease yes no
Obesity yes no
LIPIDgen Liver disease
Thyroid disease
yes
yes
no
no
Diabetes yes no
Type 1 Type 2 Unterfunktion
Osteoporosis yes no LDL level mg/dl Überfunktion
Cancer yes no HDL level mg/dl
Liver Bladder Total cholesterol mg/dl Cancer yes no
Lung Kidney Triglycerides mg/dl Liver Bladder
Colon Breast Systolic/diastolic blood mmHg Lung Kidney
Leukaemia pressure (ex: 120/80 mmHg) Colon Breast

Stomach Your medical history

Skin Diabetes yes no Barcode:
Type 1 Type 2

Sports injuries yes no Hypertension yes no

which? Cardiovascular disease yes no

Other disease(s)/disorder(s): myocardial infarction

Hyperlipidaemia yes no
Obesity yes no

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SPECIFIC QUESTIONNAIRES (PAGE 5/ 7)
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PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Leukaemia Stomach Your family medical history* Obesity yes no

Skin Hypertension yes no
please do only consider first and second degree relatives
*

(i.e. grandparents, parents, siblings, children, aunts, uncles, Cardiovascular disease yes no
neverces, nephews, grandchildren)
Other disease(s)/disorder(s): myocardial infarction
Diabetes yes no
Hyperlipidaemia yes no

Joint disorder (arthropathy) yes no Cancer yes no

OSTEOgen Periodontitis yes no

Liver
Lung
Bladder
Kidney
Digestive problems yes no Colon Breast
UV exposure seldom Inflammatory disease yes no Leukaemia
regularly which? Stomach
often Allergies yes no Skin
Skin type Type I („white“) which?

Type II („beige“) Hypertension yes no Other disease(s)/disorder(s):

Type III („light brown“) Hyperlipidaemia yes no
Type IV („medium brown“) Obesity yes no
Type V („dark brown”) Diabetes yes no Your family medical history*
Type VI („black”) Type 1 Type 2
please do only consider first and second degree relatives
*

Backaches never sometimes Kidney disease yes no (i.e. grandparents, parents, siblings, children, aunts, uncles,
regularly neverces, nephews, grandchildren)
Liver disease yes no
Decreasing body size yes no Thyroid disease yes no Osteoporosis yes no
Bad posture yes no hypofunction Fractures yes no

Your medical history hyperfunction Femoral neck

Osteoporosis yes no Vertebra Rib
Fractures yes no Parkinson’s disease yes no Wrist
Femoral neck Eating disorder yes no
Vertebra Rib Anorexia nervosa
Wrist Bulimia
Binge eating
SKINgen
Cancer yes no

PROSTATEgen Liver
Lung
Bladder
Kidney
Your medical history
Skin disease yes no
Colon Breast Acne Psoriasis
Testosterone level μg/l Leukaemia Eczema
IGF-1 μg/l Stomach Dermatitis

Environmental exposure Skin

Pesticides: insecticides, yes no

herbicides, etc.
Other disease(s)/disorder(s): Barcode:
Your medical history
Vasectomy yes no

Did you ever have syphilis? yes no Your family medical history*

please do only consider first and second degree relatives

*

Did you ever have gonorrhoea? yes no (i.e. grandparents, parents, siblings, children, aunts, uncles,
1x >1x neverces, nephews, grandchildren)

Prostate cancer yes no

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SPECIFIC QUESTIONNAIRES (PAGE 6/ 7)
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PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Imbalance of sex hormones yes no Environmental exposure Skin type Type I („white“)
Digestive problems yes no Dental amalgam yes no Type II („beige“)

Inflammatory disease yes no Pesticides: insecticides, yes no Type III („light brown“)
which? herbicides, etc. Type IV („medium brown“)

Allergies yes no Paints, solvents, glues yes no Type V („dark brown”)

which? Klebstoffe Type VI („black”)
Cancer yes no Car exhaust fumes yes no Skin condition 1 oily dry
Liver Bladder (working/living in the city) sensitive
Lung Kidney Hair dyes yes no Skin condition 2 wrinkles
Colon Breast Cleaning agents yes no acne scarring
Leukaemia Skin profile pigmentation
Stomach Regular topical application yes no UV exposure seldom / never
Skin of substances containing Vitamins/antioxidants sometimes

Regular topical application yes no regularly

Other disease(s)/disorder(s): Of substances containing Frequency of UV sunburns seldom/never
Mineral oils, alcohols, fragrances
sometimes
Make-up yes no regularly

Pain in feet or legs while never sometimes Obesity yes no

THROMBOgen walking or standing

Repeated miscarriages
regularly

yes no
Inflammatory bowel disease yes
Crohn’s disease
no

Your medical history Ulcerative colitis

Circulatory disturbances never sometimes Thrombosis yes no Kidney disease yes no

regularly Thrombophilia yes no Other disease(s)/disorder(s):
Prickling in hands/feed never sometimes Oedema yes no
regularly Atherosclerosis yes no

Tension or pain in legs/calves never sometimes Cardiovascular disease yes no Your family medical history*
regularly myocardial infarction
please do only consider first and second degree relatives
*

Swollen legs or ankles never sometimes (i.e. grandparents, parents, siblings, children, aunts, uncles,
regularly neverces, nephews, grandchildren)
Hypertension yes no

Legs feeling heavy never sometimes Hyperlipidaemia yes no Thrombosis yes no

regularly Diabetes yes no Thrombophilia yes no
Varicose veins yes no Type 1 Type 2 Cardiovascular disease yes no
myocardial infarction

Your medical history

WEIGHTgen Digestive problems yes no Stroke

Hyperlipidaemia
yes
yes
no
no
Inflammatory disease yes no
which? Diabetes yes no

Waist circumference cm Allergies yes no

(measured at the navel) which?
Barcode:
Systolic/diastolic blood mmHg Cardiovascular disease yes no
pressure (ex: 120/80 mmHg) myocardial infarction
LDL level mg/dl
HDL level mg/dl Hypertension yes no
Total cholesterol mg/dl Hyperlipidaemia yes no
Triglycerides mg/dl Diabetes yes no
Type 1 Type 2

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SPECIFIC QUESTIONNAIRES (PAGE 7/ 7)
®

PATIENT PHYSICIAN

Last name Last name

First name First name

Date of birth

Erkrankung der Liver yes no Lung Kidney Stomach Cardiovascular disease yes no
Thyroid disease yes no Colon Breast Skin myocardial infarction
hypofunction
hyperfunction Other disease(s)/disorder(s): Obesity yes no
Hypertension yes no

Skin disease yes no Hyperlipidaemia yes no

which? Your family medical history* Diabetes yes no
Osteoporosis yes no Thyroid disease yes no
please do only consider first and second degree relatives
*

Cancer yes no (i.e. grandparents, parents, siblings, children, aunts, uncles, Cancer yes no
neverces, nephews, grandchildren)
Liver Bladder Leukaemia

Hypertension yes no Alzheimer’s disease yes no

Well-being Hyperlipidaemia yes no Parkinson’s disease

Cancer
yes
yes
no
no
Diabetes yes no
Type 1 Type 2 Zum Hautprofil
Waist circumference cm Kidney disease yes no Regular topical application yes no
(measured at the navel) Hyperuricemia yes no of substances containing
vitamins/antioxidants
LDL level mg/dl Liver disease yes no
HDL level mg/dl Osteoporosis yes no Regular topical application yes no
Total cholesterol mg/dl Thyroid disease yes no of substances containing
mineral oils, alcohols, fragrances
Triglycerides mg/dl Unterfunktion

Systolic/diastolic blood mmHg Überfunktion Make-up yes no

pressure (ex: 120/80 mmHg) Skin type Type I („white“)

Mood disorders yes no Alzheimer’s disease yes no Type II („beige“)

(e.g. mood changes, depression, etc.) Parkinson’s disease yes no Type III („light brown“)
Lack of energy, fatigue yes no Cancer yes no Type IV („medium brown“)

Environmental exposure Liver Bladder Type V („dark brown”)

Dental amalgam yes no Lung Kidney Type VI („black”)

Pesticides: insecticides, yes no Colon Breast Skin condition 1 oily dry

herbicides, etc. Leukaemia Stomach sensitive

Paints, solvents, glues yes no Skin Skin condition 2 wrinkles

acne scarring

Car exhaust fumes yes no Other disease(s)/disorder(s): pigmentation

(working/living in the city) UV exposure seldom / never
Hair dyes yes no sometimes

Your medical history Your family medical history* regularly

Migraines yes no Frequency of UV sunburns seldom / never
please do only consider first and second degree relatives
*

Skin disease yes no (i.e. grandparents, parents, siblings, children, aunts, uncles, sometimes
which? neverces, nephews, grandchildren)
regularly
Periodontitis yes no Cardiovascular disease yes no
Digestive problems yes no myocardial infarction
Barcode:
Inflammatory disease yes no
which? Obesity yes no

Allergies yes no Hypertension yes no

which? Hyperlipidaemia yes no
Cardiovascular disease yes no Diabetes yes no
myocardial infarction Osteoporosis yes no
Thyroid disease yes no

Max-Planck-Straße 18 · D-54296 Trier

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