Confidential Health questionnaire


    Date of birth

    Name of person to contact in the event of an emergency:

    Due to the current environment, our fasting programs are reserved for people with no Coronavirus related symptoms and who have not recently been in contact with an infected person.

    In this case, fasting for several days would be counterproductive.

    Fasting is above all for preventive measures.

    Do you currently suffer from an acute illness or a specific chronic ongoing health issue? YesNo

    Details:

    Do you have medical or surgical history? : YesNo

    Details:

    Are you currently under medical treatment for one or more pathologies ? : YesNo

    Which one and why ?

    DO YOU CURRENTLY SUFFER OR HAVE SUFFERED FROM :

    High blood pressure : YesNo

    HypotensionHypertension

    A heart condition : YesNo

    Heart rhythm disturbancesHeart failureStent placementBreathingOther

    Details:

    Respiratory issues : YesNo

    AsthmaChronic bronchitisOther

    Details:

    Metabolic issues : YesNo

    DiabetesCholesterolUric acidOther

    Details:

    Thyroid issues : YesNo

    HypothyroidismHyperthyroidismAblation

    Allergies : YesNo

    Hay feverMedicationFoodOther

    Details:

    Kidney issues : YesNo

    kidney stoneskidney failureOther

    Details:

    Digestive issues : YesNo

    UlcerGastritisGastroesophageal reflux diseaseHepatitisGallstonesLiver failureTransit disordersOther

    Details:

    Muscle or joint pain : YesNo

    Low back painSciaticaOsteoarthritisOther

    Details:

    Sleep issues : YesNo

    Difficulty falling asleepNocturnal awakenings

    Nervous system issues : YesNo

    DepressionAnxietyBipolar disorderEpilepsyOther

    Details:

    Any other issues : YesNo

    FatiguedPanic attack/SpasmophiliaMuscle crampsDizzinessVasovagal syncope/FaintingHeadacheOther

    Details: