Name:

Sex:

Date of Birth:

E-mail Address:

Address/Phone Number:

Diagnosis of Illness:

When was diagnosed:

Do you take medicine? Medication's name:

Your main problem:

Your recent blood results (if you have any):

General health information (If genetic: who has same disease with you in your family?):

Appetite, sleeping, stools and urine condition? Thirst? Do you like to drink warm or cold water?