Energiefeldanalyse Fragebogen

Name: __________________________Therapeut: ___________________________________  

Geburtsdatum: ___________________Geschlecht: __________________________________

Adresse: ___________________________________________________________________

Tel.: ____________________________ Email:_______________________________________

Beschreibung des aktuellen Problems:

                                                                                                                                            

                                                                                                                                            

                                                                                                                                            

                                                                                                                                            

Meinung des Arztes:

                                                                                                                                            

Ihre Meinung (Intuition):___________________________________________________________________________

_______________________________________________________________________________________

Beschreibung wie das Problem angefangen hat:

                                                                                                                                            

                                                                                                                                            

                                                                                                                                            

Umweltprobleme (vorher oder während):

                                                                                                                                            

_______________________________________________________________________________________

Vorerkrankungen:

Kinderkrankheiten (einkreisen): Mumps, Masern, Röteln, Windpocken, Lungenentzündung, Keuchhusten, Scharlach,

andere__________________________________________________________________________________

Impfungen (einkreisen):

MMR, DPT, Polio, TB, Windpocken, andere________________________________________________________

Operationen (Organe entfernt?):

_______________________________________________________________________________________

_______________________________________________________________________________________

Gesundheitsprobleme leiblicher Mutter und Vater:_________________________________________________________

___________________________________________________________________________________________________

Gesundheitsprobleme leiblicher Großeltern:______________________________________________________________

___________________________________________________________________________________________________

Gesundheitsprobleme leiblicher Geschwister, Tanten, Onkel:________________________________________________

___________________________________________________________________________________________________

Zusätzliche Anmerkungen/Auslandsaufenthalte:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________