Please, print the following questioner, completed and fax it to 0030 210 6813995. Do not hasitate to call us on 0030 210 32 30 000 for any further questions.

FULL NAME:

FATHER’S NAME:

ADDRESS:

TEL.:                          FAX:                            e-mail:

AGE:                     HEIGHT:                      WEIGHT:

ΗΜΕΡΟΜΗΝΙΑ:

Please place a √ at the corresponding answers.

-   The reason for your visit is

□   Preventive testing without symptoms or known health problems?

□   Preventive testing because of some known symptom or known problem of your health?

□   Testing for a specific health problem? 

-  The last time you checked your health was

□   A year or less ago

□   2 years ago

□   3 or more years ago

□   Never before

-You were born

□     over 4 kilos?

□     under 2 kilos?

-  Have you as a teenager or adult experienced

□    A serious infection problem or contagious disease?

□    A disease for which cortizone or immunosuppressive drugs were used?

□    A serious accident or injury?

□    A surgical operation?

□    An allergy to drugs – or other allergic-anaphylactic reactions?   

□    Serious mental pressure and serious mental or somatic stess for a long perod of time?  

-   Are you aware if any of your parents, siblings, offspring, or close relatives had

a hereditary disease or predisposition for disease?  

(parents □  siblings □   offspring  □   )

A serious infection or contagious disease? 

(parents □  siblings □   offspring  □   )

A disease related to cardiac or brain function? 

(parents □  siblings □   offspring  □   )

A cancer occurrence?

(parents □  siblings □   offspring  □   )

Hypertension □        elevated cholesterol □     many triglycerides □

Urinary arthritis □      bulb or duodenum ulcer □

Diabetes mellitus □    serious obesity?

(parents □  siblings □   offspring  □   )

·A disorder for which cortizone or immunosuppressive drugs were used?

(parents □  siblings □   offspring  □   )

- Today your physical performance is

     very good   □   medium  □     bad  □

 -Your work and other regular activities need physical energy

    minimum  □    medium  □     a lot  □

-Do you work much over 8-hour?

 No □     up to 2 hours  □    over 2 hours   □

-Is it possible at your work space to have encumbering factors from

dust inhalation □     heavy metals □     gases or fumes □  

radiation  □    dangerous microbes  □

-Your house is

well-ventilated/sunny  □    spacious  □    with humidity  □   very old □  

in a ecologically aggravated area □

-You smoke

Never □    rarely  □     1-5 cigarettes/day  □   up to a packet/day  □ 

Over 1 packet/day □      cigars or pipe   □

-You consume alcohol

None   □     rarely □     up to 2 glasses/day □      2-4 glasses/day □ 

Over 4 glasses/day □

-You consume drinks/beverages with carbonate

None   □     rarely □     up to 2 glasses/day □      2-4 glasses/day □ 

Over 4 glasses/day □

-Have you ever frequently used drugs or toxic substances?

 Yes  □    no  □ 

-Have your recently experienced intense mental stress?

 Yes  □    no  □ 

-If yes, was it     at work  □       in the family □ 

-  The vitality and texture of your hair is

 high □     medium □      low □  

-  Your daily Bowel movements are

 very solid   □     median composition  □       loose □  

- The time you need to go asleep is

 a lot  □      medium □       a little  □

- The duration of your sleep is 

 less than 6 hours □         6-8 hours  □     greater than 8 hours  □

- Your sleep is

continuous  □        interrupted   □  

- Do you feel stiff when you wake up?

A lot  □      medium  □     a little  □      none  □

- Do you feel depression, stress or hyperexcitability?

A lot  □      medium  □     a little  □      none  □

-  Do you feel chronic fatigue?

A lot  □      medium  □     a little  □      none  □

-  Your ability for protracted mental concentration is

 large  □      medium   □       small  □

-  Is your skin dry, loose or with often impetigo?

A lot □       medium □      a little  □

-  Do you often feel gases in your intestine or stomach?

A lot  □     sometimes □     none □ 

-  How often do you suffer from headaches?

A lot  □     sometimes □     none □ 

- Please place a √ if you had any of the following

frequent sinusitis □      seasonal allergic rhinitis □    allergies □

skin infections □     urinary system infections □    hypersensitivity to chemical substances □     eczema or pruritus □      psoriasis or hives □  

asthma  □     

fever □       shiver □     loss of appetite □      loss/gain of body weight  □     thirst/bulimia □     

dizziness or vertigo  □     eyesight disorders □     hearing disorders □     sleep disorders □     swallowing disorders □     numbness □       convulsions  □     hallucinations □   

dry cough □     productive cough □    hemoptysis □     dyspnea  □   chest pain □       hoarseness  □

dyspnea on effort □     dyspnea at night □    pain at the back of the sternum □  throb feeling □      feet swelling  □     hypertension □    

anorexia □       nausea or vomiting  □    difficulty swallowing □    indigestion  □      abdominal pain (after the meal □   lying down □   standing up or sitting down □    continuous pain □      periodic pain  □)  constriction □      stool blood □    jaundice □     intestinal polyps □  

difficulty urinating □     blood urine or a change in their colour □   nocturnal urination □      kidney colic □ 

pain or stiffness at the joints □     myalgias □      neck pain  □     at the waist □   at the back □    

disorder at the rhythm or duration of the period □    major loss of blood during period □   intense pain and swelling during period □     miscarriages □    vaginal excretions □    use of contraceptives □     hormonal replacement after menopause