Questionnaire

History of the condition: when and how it began, symptoms, when they occur, how often they occur, what makes them better or worse, any additional complaints, and whether the condition is unchanged, worsening, or improving.

If available, please attach copies of test results, examinations and medical reports.

Conventional medicine, complementary therapies, medications

Please indicate any illnesses suffered in childhood.

Indicate known hereditary diseases in close relatives

Please indicate any hospitalizations, surgeries or injuries and the approximate year they occurred.