Select Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados 0elarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Timor-Leste Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
Please select your Country of residence.
How long have you suffered symptoms?
How do you think you got this?
Describe First Symptoms (incl. parts of body)
Anyone else near you affected
What is their age and sex and how long have they had symptoms?
Have you seen any doctors and if so what kind?
What did they tell you? What did they prescribe?
Describe what you have tried on your own to rid yourself of this?
Have you taken anything internally and did you see any results?
How was your general health before you got this?
What is your health like now?
What other health issues did you have and what kinds of medication were you taking?
Underweight Overweight Perfect Weight
Do you drink coffee or sodas? How many a day?
Do you eat junk food? How often?
What is your diet like? Describe an average day and times you eat.
What sort of work do you do?
Do you exercise and if so how often?
What do you do for exercise?
How much time do you spend outdoors?
Do you have any pets and are they affected? Describe how.
Besides your own pets do you have animals around your house?
Have you tried pest control companies?
What did they do and what did they charge you?
Is your home crowded? With what?
Please check if you have the following:
Do you have any symptoms that have been unchanged since the beginning?
If yes, what and where on your body are they?
What kind of mattress do you have? How old is it?
Does your pillow bother you?
What kind of pillow and how old?
Do you have any symptoms on your head or face? Please describe.
Do you have this in you ears or nose?
Are any areas of your skin numb?
Does eating affect the symptoms? How and what foods?
Does sweating affect the symptoms?
Did your first symptoms change to any other areas? Did they expand or go away and appear on a different part of the body?
When did it change and to what areas?
Do you currently have any activity:
Is there anything else you want me to know?