a) heart and circulation (e.g. heart defects, palpitations, angina pectoris, high blood pressure)?
b) blood vessels (e.g. haemorrhoids, varicose veins, circulatory disturbances)?
c) respiratory organs (e.g. deviated nasal septum, asthma, bronchitis, pneumonia, lung cancer)?
d) digestive organs (e.g. heartburn, gallstones, fatty liver, inflammation of the stomach/intestines, cancer of the
intestine)?
e) urinary organs (e.g. cysts, kidney stones, inflammation of the bladder/pelvis)?
f) sterility or fertility disorders (e.g. limited fertility, hormone treatment, artificial insemination)?
g) metabolism (e.g. diabetes, raised levels of blood fats or uric acid, struma with/without nodes cold or hot)?
h) blood (e.g. blood clotting disorder, tendency to thrombosis, anaemia, leukaemia)?
i) inflammatory disease of the joints or connective tissue (e.g. arthritis, morbus Bechterew, rheumatism)?
j) infectious diseases, venereal diseases, tropical diseases (e.g. hepatitis, borreliosis, shingles)?
k) brain or nervous system (e.g. epilepsy, concussion, headache/migraine, neuritis)?
l) sexual organs (e.g. myomas, cysts, breast cancer, testicular cancer)?
m) back (e.g. slipped disc, repeated tenseness, spinal syndrome, scoliosis)?
n) knee joints, hip joints, shoulders or skeleton (e.g. arthrosis, damage to cartilage/meniscus/ligaments, torn
muscles/tendons)?
o) allergies (e.g. hay fever, contact allergy, food allergy)?
p) skin (e.g. eczema, neurodermatitis, psoriasis, skin cancer)?
q) eyes (e.g. inflammation, cataract/glaucoma)?
r) ears (e.g. inflammation of the middle ear, hardness of hearing, tinnitus, hearing loss)?
s) other non-listed areas (e.g. anomalies, missing organs/limbs, foreign objects left after surgery, hernia, fistula,
malignant/benign tumours)?
5. Have you in the last 5 years been operated upon in a hospital, sanatorium or rest-cure establishment, or on an
outpatient basis?
6. Are you being treated, undergoing consultation or examination for psychological problems/illnesses (e.g.
psychotherapy, depression, separation problems, attention-deficit syndrome) or addiction-related illnesses (e.g.
through alcohol, drugs), or have you in the last 5 years undergone such treatment, consultation or examination?