Before you make your appointment for your SCIO-Analysis, please fill out the form below.

Do you need help? Contact me.



Personal

Name:*
Maiden Name
Place of Birth*
Birthday:*
 / 
 / 

If you know your Time of Birth, add it here


Time of Birth
 : 
Body Hight in cm
Body Weight in kg
Are you pregnant?
Are you wearing a pacemaker?
Gender:*
Blood-Type
Address:*
Phone:
-
Mobile:
-
E-mail:*

Questions about symptoms, diseases and lifestyle.

Alle answers are kept in privacy and will never be shared.

If you are not sure about the answer, leave the field empty. Answer the questions as good as possible.

1. What are the symptoms you want to solve?
2. What are the diseases you want to solve?
3. I have these organs removed
4. At the moment I am taking these medications
5. At the moment I am taking these hormones
6. At the moment I am taking these street drugs
7. I have these known allergies
8. I had these severe injuries and surgeries (i.g. broken bones, organ removal...)
9. I had these severe infections
10. Number of sugar type products per day (softdrinks, icecream, cake, etc.)
0
0
100
11. Number of alcoholic drinks per day (beer, wine, liquor)
0
0
100
13. Number of caffeine products per day (coffee, tea, RedBull)
0
0
100
14. Number of amalgam and/or metal fillings currently or removed during the last years
0
0
100
15. How many cigarettes or cigars do you smoke per day?
0
0
100
16. My personal stress level
1
2
3
4
5
6
7
8
9
10
In addition I want to mention:

Disclaimer:

LifePlanEarth and Oliver Zuber-Kaldenbach are not giving any medical advises, promises or guaranties. They do not make any diagnosis or treat specific health issues or health problems. The client alone is responsible for all health issues or medical treatments.

I accept the disclaimer*