Health Assessment Questionnaire -- Electronic Filing Part 1

NOTICE: This questionnaire requires MS Internet Explorer ver. 5.1 or higher to be transmitted without errors.  Using other browsers may transmit this questionnaire with distortions or not transmit at all.

To be better prepared for your appointment we ask you to fill this Health Assessment Questionnaire which is the equivalent of about two-hour interview.  It provides a substantial insight into your state of health in the context of nutritional deficiencies and allows us to understand your needs better. 

Dr. Kulisz's health improvement programs are entirely based on the use of natural substances, nutrition, exercises, and lifestyle adjustments specifically developed for individual clients.  Under no circumstances we suggest, prescribe or otherwise indicate use of synthetic medicines as the health problems are not created by the deficiency of such. 

For the scope of Dr. Kulisz's practice and office charges click here. For disclaimer click here.

There is a fee of US$49.95 for the transmission and processing of this questionnaire (US$75.00 if filed by fax) plus an additional fee for an appointment or telephone consultation ($75.00 to $250.00 depending on length and complexity).  Estimated office charges will be provided at the time of setting up the appointment. 

Please pay the questionnaire processing fee using PayPal secure payment facility

After completing the payment you will be transferred to the questionnaire page