Consultation questionnaire

30 questions in three sections, 10–15 minutes. Only 6 are required — answer the rest if you can. Your answers are saved in this browser, so you can stop and come back later.

Have your height and weight, and a list of your medicines and diagnoses ready. Photos are optional.

How the healing process works

Consultations work as a cycle: each one gives you recommendations for about a month of remedies and procedures at home. Conditions that have developed over years cannot be reversed in one consultation and one month.

Results depend on heredity, age, how advanced the condition is, and how consistently and carefully you follow the recommendations.

Section 1. About you

First and last name *

Date of birth *

Sex *

One question in the “Health” section depends on this answer

FemaleMalePrefer not to say

Phone and contact *

The country code is based on your location — please check it

Contact phone number

Preferred messaging app

WhatsAppTelegramOther

Email *

A copy of your questionnaire will be sent here

Occupation and education

Country of residence

Height and weight

Height

cm

Weight

kg

Section 2. Health

What is currently bothering you? *

This is the most important information for the doctor — please describe your main concern

What have doctors diagnosed?

Tick if you have been diagnosed with

HyperthyroidismGallstonesNo diagnoses

What treatment are you taking now, and what did you take in the last 1–2 years?

Have you been treated with hormones or antibiotics?

HormonesAntibioticsNo

Past surgeries and serious infections

NoneYes

Allergies and intolerances

NoI don't knowYes

Which of these do you experience often?

Tick all that apply

Blood pressure, temperature, and pulse

If you haven't measured these, leave blank

Blood pressure in the morning, before getting out of bed

Temperature in the morning, before getting out of bed, °C

Pulse in the morning before eating, beats per minute

bpm

Pulse 15 minutes after eating, beats per minute

bpm

Section 3. Lifestyle

Water

Do you drink water first thing in the morning before eating? If so, how much?

How much plain water do you drink per day?

Eating habits

How many times a day do you eat?

Snacks: how many times a day and what do you eat?

What time is your last meal of the day?

Cleansing procedures — have you tried them?

Enemas

YesNo

Therapeutic fasting

YesNo

Simple tests

Breath-holding: while relaxed, breathe out fully, then breathe in fully and hold your breath — how many seconds did you manage?

sec

Lemon juice: drink the juice of one lemon on an empty stomach — what was your reaction? ⚠ Do not do this test if you have an ulcer, gastritis, or other stomach or intestinal conditions

Urine pH — if you have test strips

Your notes for the doctor

Photos (optional)

Photos are not required, but they help the doctor prepare for your consultation more precisely. You can attach up to 3 photos. The most useful are:

Your tongue in the morning, before eating
Your face, close up
The area that bothers you: skin, nails

Please do not send photos of intimate areas.

Attach photos

Photos are resized on your device and are not saved in the draft.

Check your answers

Questionnaire sent

Thank you! A copy of your questionnaire will be sent to within an hour (please check your spam folder). The doctor will review your answers and contact you.

If you remember something important, simply reply to the email.

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