Patient’s questionnaire

If you want to consult Ton Jansen or Dr. Peter Naydenov, please call (or sms) Ton at +31174297052 or Peter at +359888540442 to arrange an appointment in person or by Skype. Before the consultation, please fill in this questionnaire. For this purpose, copy this text (Ctr+A, Ctr+C). Open a new text file (MS Word, Notepad) and paste the copied text there (Ctr+V). Add your answers where needed, and describe detailed and comprehensive your complaints, as well as your typical psycho-emotional states, without hiding anything. Delete what’s unnecessary.

Questionnaires filled with yes or no or with evasive answers only waste our time. So please fill in correctly the questionnaire – your treatment depends on this! A properly completed questionnaire is actually a detailed story of your life and your complaints – a sort of a honest confession.

Send the completed questionnaire by email to (Ton) or (Peter). Your information is strictly confidential and your privacy is guaranteed.

Name, Surname
Date, time and place of birth
Height cm Weight kg

Issues related to homeopathic detox:
Every disease, poisoning, drug or accident leaves a mark on the body and weakens him. Homeopathic treatment takes into account all the details of the past to eliminate problems and to strengthen weaknesses. It is therefore necessary to know all your medical history and treatment performed.

What vaccines have you got? DTaP, IPV, Hib, MenC, MMR, HPV, typhoid, PPV, Hepatitis A, Hepatitis B, BCG, influenza, swine flu, cholera, rabies, tetanus, others (which). Were there any stronger reactions and other problems after vaccination? Describe in detail!

Which vaccines were given to your parents up to 10 years before your conception?

What kinds of allopathic treatment did you receive?

What allopathic drugs did you take or are taking now?

From what diseases and with what drugs are treated your parents?

What treatments received your mother while she was pregnant with you – for example, dental treatment under local anesthesia, amalgam fillings, iron injections, antiemetic drugs, drugs against contractions, vaccinations, cortisone ointments, operations with general anesthesia, etc.

Did your mother use allopathic drugs during your birth? If so, which – for labor induction, pain relievers, anesthetics, sedatives, hypnotics, antibiotics, etc.

If possible, bring with you the medical history of your birth, as well as your health and medicine history.

History of your diseases and detailed information about them

Leave only the diseases which you have had. Delete the rest.
Typhoid, cholera, food poisoning, Worms, Dysentery, Varicella, Measles, mumps, rubella, pertussis, diphtheria, malaria, jaundice, hepatitis, other diseases of the spleen, liver, gall bladder,

Abortions and miscarriages. Nausea during pregnancy Prolapse of the uterus

Digestive problems, diabetes, rickets, rheumatism, back pain,

Venereal diseases: syphilis, gonorrhea, trichomonasis, chlamydiasis, genital warts, other.

Heart diseases, hypertension, dizziness, chronic headaches, urinary problems, kidney disease

Operations – Tonsils, Appendix, Hernia, Hemorrhoids, uterus, kidney stones, gall stones, phimosis, hydrocele, prostate disease,

Cataracts, conjunctivitis, myopia, glaucoma, other eye problems

Frequent tonsillitis, adenoids, sinusitis, pneumonia, asthma, tuberculosis, bronchitis, pleuritis,

Major bleeding from any part of the body

Skin diseases, rashes, boils, carbuncles, Fungus, Scabies, Eczema, Hives, Allergies, Herpes, Psoriasis, Other

Great stress: Grief, disappointment, fear, nervous breakdown, failure in performance, love disappointment, Financial loss (please explain).

Numbness, cramps, convulsions, seizures, Polio, paralysis, meningitis, lumbar puncture

Accidents, Injury of the head and body, unconsciousness, concussion general or local anaesthesia

Illness in the family: Anemia, epilepsy, other seizures, Madness, Rheumatism, Hypertension, sick, heart attack, stroke, paralysis, cancer, diabetes, ulcerative colitis, bleeding easily, Urticaria, Asthma, Eczema, Psoriasis, Arthritis, Scabies, tuberculosis, pleuritis, malaria, liver, kidney,

Relatives – describe you are living and what diseases suffer if they are not alive – what died
Maternal grandfather

Maternal grandmother
Paternal grandfather
Paternal grandmother

Your birth and childhood (especially important for children patients). If you have no information, delete the relevant text:
Did the mother have problems during pregnancy? Was she taking any medicines? What? Were there any problems at birth? What?
At what age did you first teeth appeared? When did you start talking and walking? When you stop to pee at night? Did you eat chalk, earth, sand, etc..? What other problems you had as a kid?
Any animal’s bites – what and when?

Your family: Date of birth; Health problems

Unhealthy habits (note +++ much; ++ often; + sometimes; – not)
black tea

Main complaints: Describe in detail

Origin and cause of complaints: Can you trace the beginning of the present suffering and link it to any particular circumstances, accident, illness, mental and physical overload, emotional problems, shock, worry, errors in diet, cold, heat, etc.

Appetite and thirst:
How do you rate your appetite? When are you most hungry? How fast do you eat? What happens if you can’t ear for a long time, and you“re hungry?
How thirsty are you? For hot or cold drinks? How much fluid you drink a day, incl. tea, juice, soup, etc..? What time of the day are you especially thirsty an hungry?
Do you have a change in taste or specific sensations in the mouth?
Note food and drink preferences by copying the appropriate foods in those places. Delete the foods to which you are indifferent!
+++ I crave:
++ I like a lot:
+ I sort of like:
> I feel better by eating:
– – – I hate to eat and do not eat ever:
– – I do not like to eat:
– I can eat, but don’t like:
< I feel worse by eating:
Bitter, salty, sweet, sour, pungent, Spices, Smoked Foods
Fish, Chicken, Meat, Milk, Cheese, Beans, Rice, Cabbage, Onions, Fruits, Vegetables
Oil, grease, pasta, eggs, cream, chocolate, coffee, smoked foods, Oranges, Bananas
Hot food, hot drinks, cold food, cold drinks, other food (describe what)

Bowel movement:
Any problem with defecation? How many times a day? Do you have constipation or diarrhea? Do you need to push hard? Is your belly swollen? Do you have gas?

Any problems with urination – before, during, after? Urine smell? Difficulty in urination – start slowly, trickle, interruption, dropping. Bed wetting, involuntary urination – when sneezing, coughing, laughing, walking, etc.

How much you sweat and when – day, night, sleep, exertion, etc.? Which parts of the body – hands, feet, axillae, head, others. Describe your sweat – hot, cold, sticky, oily, honey-like, staining the underwear (what color). Sweat smell – sour, spicy, urine, unpleasant, elder blossom, etc. Is it easy to wash out? Is sweating associated with any symptoms? What and when – before, during, after?

Fever, chills, colds
Have you had a long time high temperature? What was it related to? What happens when you have fever – shivering, sweating, thirst, fatigue, mood changes? Do you feel burning or coldness in head, hands, feet, etc.? Nasal discharge – watery, hot, makes the skin sore, corrosive, thick, purulent, profuse, color, taste.

Breathing problems:
Inhalation, exhalation, time of onset, the influence of cold, heat, open air, posture, etc.? Describe your cough.

Desire for sex – big, medium, low, when. Sexual excesses and their effects on health and mind. How do you feel before, during and after sex – refreshed, tired, sleepy, sad, any pain, etc. You have sexual deviants? Masturbation – how often, how do you feel then?

Erection, ejaculation, prostate problems

Menses – frequency, regularity, duration. At what age began the menstruation, was there a problem? Menstrual flow – amount, color, clots, smell, texture. Easy to wash out or not? Complaints before, during and after menses: physically, mentally.
Uterus: prolapse, dragging sensation, pain, fibroids, other
Ovaries and tubes: cysts, inflammation, pain
Vagina: itching, soreness, pain, cramps, inflammation,
Leucorrhea: color, texture, smell, related to menses, other influences?
Are external genitalia too much touch-sensitive (even from the underwear)?
Breast – swelling, pain, lumps, etc.
Abortions and miscarriages: when, in what month, number, complaints after them
Problems with menopause:

Physical symptoms:
Please describe in detail all important, strong and recurrent symptoms and their modalities – in response to heat, cold, motion, rest, effort, sleep, nutrition, sex, menstruation, sun, wind, etc.
Dizziness, fainting, headache
Eyes and vision
Ears and hearing
Nose and sense of smell
Mouth and taste
Lips – herpes, cracking,
Tongue – coating, cracks, indentation
Teeth, gums
Throat, tonsils, swallowing
Heart, blood pressure, blood vessels
Spine, Extremities, Joints
Skin, nails, hair
Wound healing – quick, slow, suppuration, keloids
Bleeding tendency
Pain, swelling, numbness, paralysis
Affected side – right, left, passing from one to another, how exactly
Tremor, weakness – in which parts, when?

Common modalities:
Different circumstances affect us differently. Some people get headache in the sun, others hate the winter, still others are very sensitive to drafts, and so on. Below indicate exactly how you are affected by the factors listed, especially the effects on the main complaints. For example, if you have a headache and it is better when lying down, write „headache ameliorates when lying.“ If any one factor worsens one complains and improves another, write it down – for example, “Eating ameliorates the headache but worsens the pain in the abdomen“
This information is vital for your healing. Please answer in detail focus on the most important things.
heat, cold, rain, sun, cloud, fog, thunder
Watching: up, down, high, moving objects
Sea, Mountain
Music (sudden) noise, light, smells
seasons, changing seasons
warm bath, cold bath, bathing in the sea
Defecation: before, during, after
Urination: before, during, after
running, walking, climbing, descending, physical effort
Riding: car, boat, airplane
Speaking, Reading, Writing
Lying: on belly, on back, on left/right side
Bending, sitting, standing
Before an important meeting, before exam
Menses: before, during, after
Anger, anxiety, sadness, crying, comforting, Laughter, Thoughts about disease
Eating, drinking, fasting
Sweating, getting feet wet
Crowd, outdoors, in a closed room
New moon, full moon
touch, pressure, massage
Morning, noon, afternoon, evening, night
Tight clothing
Sleeping: before, during, after; lack of sleep, afternoon nap
Draft of air, wind, smoke, dust
Sight of blood
Coughing, sneezing
Alone, in company
Swallowing, belching, Yawning

Position of sleeping; is there a position where you cannot sleep?

What happens during sleep: snoring, teeth grinding, drooling, sweating, mouth open, eyes open, restlessness, moaning, speaking, walking, crying, uncovering parts (which), startling, arousal (why), others.

Dreams: Leave the recurrent dreams. Delete the dreams that don’t apply to you:
animals: dogs, cats, horses, wild animals, snakes; robbers, thieves, anxiety, fear, ghosts; Trips, ride, Flying, Swimming, drowning; houses, fruit trees, water, snow; death (whose), dead, dead people, body parts; Accidents, accidents, falls, homicide, suicide; you“re thirsty, you drink, you“re hungry, eat it; fire, lightning, storms, rain; Shooting, War; talking, singing, dancing; pleasant things romantic love; business, money, work, from the day forgotten; vomiting, defecation, urination, bleeding; sex, rape, nudity; Pain, sickness, unwell, Mutilation; prayers, religious, temples, churches, God; failures release train failure exam unprepared; sorrow, lamentation, grief, strife, jealousy, insults; Police closing, crime, murder; Uncertainty Hazards Chase – who, why; physical and mental effort; events: distant, recent, future prophetic; People, Children, Holidays, Other (specify details)

State of mind
Mild has a huge impact on the body. For proper treatment it is essential to understand your emotional and mental state. The questions below are asked to find out how we can help you. Please answer honestly, carefully and thoroughly. The information obtained from you will help your treatment to act beneficially on all levels – mental, emotional and physical. Ignoring the important things interferes with your treatment. Answer honestly and completely. Delete what’s unnecessary.
Are you worried? What about?
Do you have any fears – of animals, people, alone, dark, death, disease, robbers, noises, thunder, in the future, something unknown, high, other (describe exactly).
Are you distrustful and suspicious? On what topics?
Are you jealous? To what and whom? What symptoms occur when you feel jealous?
Are you often in a hurry? Under what circumstances?
If someone has hurt your feelings, how long do you remember, can you forgive? And forget? Do you sometimes wish for revenge?
What are you proud of? Can your pride be hurt easily?

Are you depressed? Do you tend toward negative thoughts?
Have you considered suicide? Why and how?
What brings you joy and uplifts your mood?
Do you often think of sex? What exactly?
Do you hear voices, or someone calling you by name?

Is there anything else that worries you?
Any memory problems – for names, places, people, things you“ve read or want to say, words, etc..
Do you weep easily or not at all? For what? How do you feel after you cried? Can you weep in presence of others or only when alone?
How do you react to sympathy and consolation? Are you compassionate?
Are you irritable and for what reason?

Do you often get angry and for what reason? What do you do when you get angry? What bodily symptoms appear?
Do you prefer company or solitude? Do you have intolerance or aversion to someone? Describe in detail.
Are you ordered or scattered? How does lack of order affect you? Are you fastidious, perfectionistic, squeamish, and picky – give examples?
What are the greatest sorrows in your life?
And the greatest joys?
Out of what you do, what you enjoy most? And what you enjoy least?
What do you like and dislike in yourself? What is that worries you and yet you can’t change it?
And what about the people you live with? Is there someone who brings you often negative emotions?
Clearly and concisely describe the situation in your family, at your work, with your friends and colleagues.
Is there anything you would not admit to anyone, even to yourself?
If you may have only three wishes, what would they be?