Questionnaire

Please complete the following questionnaire. If you can, use a different color for your answers. You can either copy the entire questionnaire and paste it into an email to me at knic2 at verizon.net and answer the questions or you can copy it and then store it in your word program and return to me as an attachment in your email. 

If attaching, please return as a doc document instead of a pdf or any other format–other formats will not be accepted. 

When I receive it, I will provide you with a free evaluation and protocol to get your life back. Please do not mail it into our office–we do not accept questionnaires by mail.

All information you supply is confidential and will not be shared with any other entity.

1. Your name                                                                       Today’s Date                   Age

2. Address:

3. email address

4. Place an X and any comments beside the following symptoms that you have

  • Non healing lesions or sores.?
  • Deep unsightly facial lesions?
  • Fibers or filaments on skin at various non-healing sites where the skin parasites reside. You can see it with the use of a jewelers loop and they are also fluorescent under a ultra violet light?
  • Bugs or bug like things coming from your skin.
  • Cotton or lint-like substance on your clothing/bedding/body without any reasonable explanation.?
  • Grayish spider like veins just under the skin
  • Intense itching skin?
  • Stinging or biting
  • Burning sensations on the skin?
  • Hair loss?
  • Chronic fatigue?
  • Brain fog?
  • Hard nodules under the skin?
  • Fibromyalgia or joint swelling and pain?
  • Black specs on the skin and bed sheets?
  • Do you have any intestinal or digestive problems?
  • Do you ever feel like something is jumping on your ankles or legs? But it is invisible?
  • Do you have a lot of activity around your eye lids and eye lashes–a crusty feeling?
  • Is your body temp 95-97 degrees instead of 98.7?
  • If your temperature is low, has it always been low?
  • Do you feel something crawling on your skin but it’s invisible?
  • Do you have rashes on your skin?
  • Do you have upper abdominal pain or burning?
  • Do you have diarrhea or alternating diarrhea and constipation?
  • Do you have a cough?
  • Any red hives near the anus?
  • Any vomiting?
  • Have you had weight loss since the beginning of your infection?.

5. When (approximate date) did you first notice the symptoms?

6. If you know how you were infected, briefly describe how it happened.

7. What treatments are you presently using?

8. Do you follow the parasite message boards?

9. Are your skin reactions limited to certain areas of your body area? If so, please describe.

10. Do you know if you have: (Yes), (Think so), (No), or (Don’t Know)

  • Morgellons
  • Strongloides Seracolis
  • Collembola

11. What is your weight?

12. How many pounds over or under weight are you?

13. Male/Female?

14. Have your received any diagnosis regarding parasites?

15. Do you have any other diagnosis for other medical problems?

16. Do you itch more or feel more biting when using a computer or are around and EMF (electromagnetic field) source?

17. Have you infected anyone else with parasites? If so, describe:

18. Do you have a sleeping partner or anyone with whom you have close body contact? Has you sleeping partner become infected?

19. Please describe your eating habits.

20. Do you use ammonia or bleach on your body? Please note that ammonia is a neuro toxin and should never be used on your skin. 

The information you provide is confidential and your name, email address or physical address will not be shared with any other entity