You have health problems and would like to get healthy again:

or: You would like to know 'preventively' in which health system problems can be expected:

Then complete the free questionnaire from five health systems

This questionnaire will be sent to the SSL secured server of the Center for Preventive Medicine. The data is processed securely and a logarithm determines your 'percentage of health reduction' in the relevant systems. You will receive the results after about 2 to 3 working days. Your Preventionist of choice will then contact you to make an appointment for an explanation

You will then know what the cause of your complaints is and you will work with your Preventionist to get healthy again

If your 'health reduction' in the relevant health system is higher than 30%, you can work on your health curatively or preventively.
Usually you already have more or less complaints in that system. Here you will receive no-obligation advice to do an additional health test to get more clarity into the cause of your complaints
To measure is to know...

Fill in the questionnaire below as honestly as possible and send it to our SSL secured server.

This calculates your 'Health Reduction' in all 5 Health Systems which is displayed from 0% to 100%.
After approximately 2 to 3 working days, you will receive six digital A4 reports in PDF (5+1 summary).
Your Preventionist will then contact you to make a call appointment for an explanation. This call is free of charge!

(All rights reserved. Nothing from this complete questionnaire may be reproduced and/or made public by means of printing, photocopying, microfilm or in any other way and/or by any other medium, without prior written permission from CPG/John Verhiel)

Vul alle verplichte velden in.
My reference is: *
Otherwise:
First name: *
Surname: *
Street and house number: *
Zip code: *
City: *
Date of birth: *
Gender: *
E-mail address: *
Telephone number: *
Length: (in cm) *
Weight: (in kg) *
What are your (main) complaints? *
If medication is used, you can indicate this on the right. It is important to know that medicines often 'mask' certain symptoms because they have an anti-symptom effect, but not address the deeper cause. This can lead to answering some questions woth 'No' while this would not be the case without medication use. Please take this into consideration when completing the questionaire. *
Start of the Acidification Questionnaire:
Infections: *
Inflammation: *
Joint problems: *
Pain: *
Fibromyalgia: *
Joint inflammation: *
Gout: (Inflammatory arthritis) *
Rheumatism: *
Arthritis: *
Arthrosis: *
Heartburn: *
Acid reflux: *
Burping: *
Stomach mucosal inflammation: *
Duodenitis: (Inflammation of the duodenum with abdominal pain) *
Muscle cramps/calves: *
Increased blood pressure: *
Tooth decay/bad teeth: *
Depression: *
Anxieties: *
Sweating attacks: *
Flushes: *
Osteoporosis: *
Burning pains: *
Hyperactivity: *
Allergies: *
Palpitations: *
Muscle weakness: *
Myalgia: *
Fatigue: *
Irritability: *
Insomnia/poor sleep: *
Cramp/calves: *
Headache: *
Migraine: *
Premenstrual syndrome: *
Irritability: *
Tensions: *
Rapid heart rate: *
Hair loss: (had) *
Heart attack: (had) *
Hallucinations: *
Trembles/trembling:: *
Muscle weakness: *
Low appetite: *
Diarrhoea: *
Vomit: *
Vertigo: *
Overall weakness: *
Muscle injury: *
Weak reflexes: *
Irregular pulse: *
Poor heart and/or kidney function: *
Reduced blood pressure: *
Apathy: *
Cardiac arrhythmias: *
End of acidification questionnaire:
**********
**********
Start questionnaire Intestine (Part 1: Immunity)
Intestinal infections: (or had) *
Itching of the anus: *
Itching of the nose: *
Crohn's disease: *
Ulcerative collitis: *
Constipation: *
Obstipation: (defecation less than 3 times a week) *
Constipation: (defecation less than 2 times a week) *
Flatulence: *
Burping: *
Mouth odor: *
Immune problems: *
Allergies: *
**********
Start questionnaire Intestine (Part 2: Fungal and/or yeast load)
Immune problems: *
Flatulence: *
Mouth odor: *
Itching of the anus: *
Itching in the ears: *
Yeast infection in the vagina: *
Vaginal discharge: *
Fungal nails: *
Intestinal infections: *
Cold hands and/or feet: *
Poor digestion: *
Heartburn: *
Sugar/sweet cravings: *
Irritability: *
More frequent headaches: *
Poor memory: *
As if 'fog in the head' *
Vertigo: *
Recurrent depressions: *
Menstrual problems: *
Prostate inflammation: *
Urinary tract infection/bladder infections: *
Hay fever: *
Runny nose: *
Frequent coughing: *
Athlete's foot: *
Skin rash: *
Psoriasis: *
**********
Questionnaire Intestine: (Part 3: Parasites)
Abdominal cramps and/or abdominal pain: *
Diarrhoea: *
Increased urgency of stool: *
Pulpy stools: *
Feces stick to the toilet bowl: *
Undigested food: *
Constipation alternating with diarrhea: *
Nausea: *
Starch (gluten) intolerance: *
Itchy skin: *
Fatigue: *
Lack of appetite: *
Children/growth retardation: *
Anemia: *
Insomnia and/or poor sleep: *
Depression: *
Muscle weakness and/or muscle pain: *
Joint pain: *
Headache: *
Flu-like symptoms: *
Fever and/or elevation: *
End of questionnaire Intestine:
**********
**********
Start questionnaire Fatty acid metabolism: (Part 1)
PMS/Stressed before menstruation: *
Tensions: *
Irritability: *
Arguing just before menstruation: *
Migraine: *
Headache: *
Skin inflammations: *
Pimples: *
Fistulas: *
Cysts: (Had) *
Contact eczema: *
Congenital eczema: *
Psoriasis: *
Asthma: *
Bronchitis: *
Shortness of breath: *
Breathing problems/pressure on the chest:
Inflammation: *
Pain: *
Rheumatism: *
Rheumatoid arthritis: *
Arthrosis: *
Gout: *
Painful swollen toe joint: *
Fever: *
Underweight: *
Overweight: *
Blood clot: (had) *
Myocardial infarction: (had) *
Stroke: (Tia)(had) *
Thrombosis: (leg)(had) *
Pulmonary embolism: (had) *
Ulcerative collitis: *
Hormonal disorders: *
Thyroid problems: *
Ovarian cysts: (had) *
**********
Start questionnaire Fatty acid metabolism: (Parts 2 and 3)
*****MG*****
Cramps: *
Irritability: *
Tensions: *
Nervousness: *
Trembles/trembling: *
Muscle weakness: *
Low appetite: *
Diarrhoea: *
Fatigue: *
Vertigo: *
*****ZN*****
White spots on the nails (hand and/or toe) *
Less resistance: *
Reduced sense of taste and/or smell: *
Slow wound healing: *
Hair loss: *
*****B6*****
Red scaly skin: *
Irritability: *
Depression: *
Headache: *
Calcified toenails: *
*****B3*****
Fatigue: *
Muscle weakness: *
Low appetite: *
Bad breath: *
Feeling depressed: *
Poor sleep: *
Forgetfulness: *
Muscle weakness: *
Painful limbs: *
Skin rash: *
Sensitive to sunlight: *
Rough skin: *
*****C*****
Less immune resistance: *
Bleeding gums: *
Catarrh: *
Shortness of breath: *
Frequent bruising: *
Joint pains: *
Loose teeth: *
Drowsiness: *
End of Fatty Acid Metabolism Questionnaire:
**********
**********
Start Sugar Metabolism Questionnaire (Part 1):
Fatigue:
Dips or slumps after meals: *
Then a feeling of being on the couch for a while: *
Occasional daytime dip: *
Then craving some food: *
Preferably sweet: *
Preferably savory: *
High Sugar Consumption: *
Or in need of (a lot of) sweetness: *
Feeling better after eating something sweet: *
Very thirsty: *
Hungry again fairly quickly after a meal: *
Tendency to consume alcohol: *
Lacking energy or interest: *
Feeling very tired: *
Tremble: *
Inner turmoil: *
Depression: *
Lust or urge to cry: *
Abstraction: *
Weak ability to concentrate: *
Fearful: *
Unmotivated fear: *
**********
Start Sugar Metabolism Questionnaire (Part 2):
Vertigo: *
Headache and/or migraine: *
Insomnia and/or poor sleep: *
Faint: *
Irritability: *
Woman: little appetite for sexuality: *
Man: it doesn't work so well anymore: *
Cramps: *
Myalgia: *
Sweating a lot: *
Cold sweats: *
Flushes: *
Nightmares: *
Palpitations: *
Suicidal tendencies or thoughts: *
Hopelessness: *
Claustrophobia: *
Constipation: *
Obesity/overweight: *
Leanness/Underweight: *
Quick bruising after punch: *
Pain on the left side of the abdomen: *
Allergies: *
End of Sugar Metabolism Questionnaire:
**********
**********
Start questionnaire Neurotransmitters: (Part 1 of 4)
Smoke: *
Drink: (alcohol) *
Stimulants: (drugs/weed) *
Energy drinks: *
Increased body weight from early 20s: *
Difficulty starting or completing tasks despite having enough energy: *
Libido good: *
Emotion eater: *
Difficulty concentrating: *
Irritable: *
Suffering from stiff joints: *
Suffering from cramps, spasms or trembling muscles: *
Suffering from acid reflux: *
Difficulty falling asleep: *
Still energy left in the evening but problems starting up in the morning: *
Feeling of being quickly knocked out of the field: *
**********
Start questionnaire Neurotransmitters: (part 2 of 4)
Sleeping problems/problems sleeping through the night: *
Tendency to eat when you're not actually hungry: *
Less adventurous than before: *
Difficulty making decisions and deliberating for a long time: *
Persistent negative thoughts and feelings: *
Difficulty coping with conflicts and times of stress: *
Small problems magnify into life-threatening situations: *
Thinking about suicide: *
The environment sometimes reacts that you are negative or difficult to deal with: *
Feeling of being constantly in survival mode and not enjoying life to the fullest: *
**********
Start questionnaire Neurotransmitters: (part 3 of 4)
Being easily frightened: *
Out of body feeling: *
Difficulty breathing or shortness of breath: *
Sweaty hands: *
Cold hands and/or feet: *
Excessive worrying: *
Always take into account worst case scenarios: *
Feeling overwhelmed easily: *
Busy Mind: *
Headache: *
Compulsive actions and/or thoughts: *
Unexplained feelings of stress and/or panic and/or anxiety: *
Feelings of doom: *
Fast or irregular heartbeat: *
Difficulty turning off thoughts: *
Difficulty focusing: *
**********
Start questionnaire Neurotransmitters: (part 4 of 4)
Impaired memory, visual and/or verbal and/or cognitive and/or auditory: *
Decreased creativity: *
Poor word recall and/or loss of comprehension: *
Difficulties with mental brainpower: *
Difficulty recognizing faces: *
Slow Mental Response: *
Less good spatial orientation and/or awkwardness: *
Scattered/scatterbrain: *
Hair loss: *
Difficulty remembering addresses and/or phone numbers: *
Alzheimer's or dementia runs in the family: *
End of questionnaires Neurotransmitters:
ATTENTION (1)!! After you have clicked on 'SEND', the following text should appear in the box on the right.
ATTENTION (2)!! After you have just clicked on 'send', please add the e-mail address listed on the right to your 'Contacts'.
END OF ALL QUESTIONNAIRES:
* Mandatory fields

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