Hrvatski

holistic medicine center

DR MED DARKO MARĐETKO

Health questionnaire

Only for adult person of age

1. What is your main health problem?

2. For how long do you have this problem ?

3. If , at the moment, you have more then one health problem, please list them in order of their importance to you

 

4. Have you ever before suffered from some serious disease ? If YES, please state which one(s)


5. Have you ever suffered from a physical trauma ( car accidents , work accident, bone fracture, surgery ) . If YES , please state which one(s)


6. Have you ever been exposed to any of psycho-emotional traumas such as : violence in a family , emotional abuse , sexual abuse, alcoholism in a family , suicide in a family , any of family members being in a prison , lost of one or both parents , emotional neglect by parents, death of a spouse , divorce , lost of a job, bankrupt . If YES please state which one(s)

7. Please state whether the traumatic experience was expected or happened unexpected and found you unprepared?


8. Does your mother or someone from her relatives suffer or had suffered from some serious disease(s) like cancer, diabetes , heart failure , arthritis , tuberculosis , psychosis etc . ?


9. Does your father or someone from his relatives suffer or had suffered from serious disease(s) ? If yes please state which one(s)


10. Does your brother(s) or sister(s) suffer of had suffered from serious diseases ? ( if you are a single child please skip the question )


11. What is your profession ? If you still study , please state what


12. Are you employed ? Do you have a steady work ?


13. Have you been exposed to harmful influences , i.e. toxic chemicals , noise, extreme heat or cold , electromagnetic pollution


14. Please estimate numerically from 1 do 10 the level of satisfaction with your work
( 1 = minimal satisfaction ; 10 = super satisfaction )


15. Do you frequently feel tired ? If YES please grade the level of your tiredness numerically from 1 to 10 ( 1 = minimal tiredness ; 10 = maximal tiredness )

16. How many hours do you usually sleep a day ?


17. When do you usually go to sleep and when do stand up ?


18. Do you have a time for a nap during the day ?


19. What is your preferential hobby ?


20. What type of water do you drink – rain water, tap water , bottled water or filtered water ?


21. What is your average daily water consumption?


22. Do you drink alcohol beverages ? If yes , how much ?


23. Do you smoke ? If yes , how much ?


24. Are you regularly exposed to the sunlight at least twenty minutes a day ?


25. Do you exercise regularly at least half an hour a day ?


26. What do you usually eat for a breakfast ?


27. What do you usually eat for a lunch ?


28. What do usually eat for a dinner ?


29. How many meals a day do you usually eat ?


30. What kind of the food you like the most and what type of the food you eat the most
frequent ?


31. Do you consider yourself as being a religious person ? If yes, please state what religion
do you follow ?


32. Do you read any spiritual literature that is not necessary connected with the mainstream
religions ?


33. Are you interested in paranormal phenomena ? Do you believe in miracles ?


34. Do you have good and honest friend ? Grade the quality of that relationship from 1 to 10


35. Please make an estimation from 1 to 10 of the relationship with your mother ( no matter
wheather she is alive or deceased )


36. Please make an estimation from 1 to 10 of the relationship with your father


37. Please make an estimation from 1 to 10 of the relationship with your brother(s) or
sister(s) ( if you are a single child skip this question )


38. If you are married , please grade from 1 to 10 the quality of the relationship with your
spouse


39. If you are engaged in extramarital relationship , please grade its quality from 1 to 10


40. Do you have a feeling of being loved in your marriage or in your extramarital
relationship?


41. If you have children , please grade the quality of your relationship with them from 1 to 10


42. Have you ever committed an abortion due to a medical reason ?


43. Have you ever committed an abortion by your own will ?


44. Do you thing you live your life according to your inner expectations and visions ?

45. Make an estimation from 1 to 10 about how much have you been satisfied with your life in total ( 1 – completely unsatisfied ; 10 – absolutely satisfied )