Hidden Infection Self Check List Part 2 Horowitz/MSIDS 38 Point Symptom Checklist First Name * Last Name How can we apply to you? * Mr Mrs Ms Other How old are you? * Have you had a tick bite with no rash or flue like symptoms? * Never Sometimes Most of the time All of the time Not applicable You have had a tick bite, an Erythema migrans or undefined rash, followed by flu-like symptoms? * Never Sometimes Most of the time All of the time Not applicable Do you experience migratory muscle pain? * Never Sometimes Most of the time All of the time Not applicable Do you experience migratory joint pain? * Never Sometimes Most of the time All of the time Not applicable Do you experience tingling/burning/numbness that migrates and/or comes and goes? * Never Sometimes Most of the time All of the time Not applicable Do you have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia? * Never Sometimes Most of the time All of the time Not applicable Do you have received a prior diagnosis of a non specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis)? * Never Sometimes Most of the time All of the time Not applicable Do you have had a positive Lyme test (ELISA, Western Blot, PCR)? * Never Sometimes Most of the time All of the time Not applicable Email * Contact PHONE number starting with area code (Example: 357 99123456 or 61 - Australia or 44 - UK) GDRP Agreement. I consent to having this website my submitted information so they can respond to my inquiry * I agree Submit If you are human, leave this field blank. Still not sure or have other questions? Enroll NLS Diagnostic session to analyse full body imbalances, hidden viruses and bacteria: Free Consultation Inquiry Form Name * First Last * Last Phone (example: 357950123456) * Email * I would like to receive Bio-resonance Cyprus News Letters * Yes Yes but not too often How many years have you been experiencing symptoms of your primary concern? * 1 -5 year 5 - 10 years More than 10 years What is your primary diagnosis if known? Have you ever been misdiagnosed? * Yes No Have you ever attempted to treat your symptoms? * Yes No Do you know about Bioresonance/NLS diagnostics Analysis Program? * Yes No Do you want us to send you Bioresonance/ NLS Diagnostics Full Guidance and contact you in person? * Yes No Do you want to book Free Consultation and we call you back to agree on date and time? * Yes, call me back today (Hours: 08.30-20.00 on Mon-Fr and 10.00 -16.00 on Saturday) Yes, call me back tomorrow (Hours: 08.30-20.00 on Mon-Fr and 10.00 -16.00 on Saturday) I will get in touch later GDRP Agreement. I consent to having this website store my submitted information so they can respond to my inquiry. * I agree I consent Text Submit If you are human, leave this field blank. Or just write to us: Contact Us Name * First Last * Last Phone (example: 357960123456) * Email * Message * Submit If you are human, leave this field blank.
