2023 PUNA quest optional stripe 275, send link!

1
What is your first (living) name and your family (house) name?* This field is required.
First Name
Last Name
2
What is your preferred title?* This field is required.
Miss
Mrs
Mr
Ms
Living Man
Living Woman
3
How do you like to be called?* This field is required.
4
What is your date of birth?* This field is required.
Date
Day
Month
Year
5
What is or was your main occupation and your favorite hobby(s)?* This field is required. (a lot of professions and some hobbies have influence on tooth aging)
6
What is your home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Phone number* This field is required.(Preferably your cell phone)
Area Code
Phone Number
8
It is helpful to communicate securely when you have a Telegram messenger account, if so please give your account name here and send us a message @punaspa
9
Email* This field is required.It would be helpful if you take a (free) protonmail.com address so we can correspond securely or use Telegram messenger
example@example.com
10
Next of kin:(name of your next of kin or close friend and his/ her phone contact in case of ?)
11
Who were you referred by:* This field is required.We need to know what member referred you as only members can bring in new members and vouch for them
12
I pledge to Article 1:* This field is required.The goal of the Puna Health Spa Private Club is to find ways and providers to help restore, facilitate, and promote health and oral health and personal empowerment for its members based upon principles of balanced natural healing (BRACED) as promoted by Fre,, House of Timmermans. The principles are based on Natural Law which includes the essence of balance and equity between physical, mental and spiritual health and honors personal values and beliefs.
Yes, I agree
Other
13
I pledge to Article 2:* This field is required.Freedom to choose or refuse any medical, dental or holistic treatment is an essential human right and this can never be changed. Creating emergency laws, acts or mandates using biosecurity fear to reduce essential human rights resembles enslavement, which is a crime against humanity (Nuremberg Code Principle). Receiving care from well trained professional healthcare workers who are pro-choice and in good health is an acceptable low risk for any person and members are aware of this and prefer this care for themselves.
Yes, I agree
14
I pledge to Article 3:* This field is required.It is important that adequate time will be spend on diagnosis, treatment planning, information, prevention, fee transparency and informed consent. The member is free to choose any follow up care or consultation. The contribution or gift is a donation of $130 for first entry and $145 per year
Yes, I agree
15
I pledge to Article 4:* This field is required.This membership is a privilege and not an entitlement to access the services of the Puna Health Spa (on average 200 working days per year availability during normal office hours). In case of unforeseen accidents or acute illness when we are temporarily not available we advise to check our website first for self care tips and when necessary seek care in the appropriate disease and illness- based emergency departments or hospitals to which you retain access.
Yes, I agree
16
I pledge to Article 5:* This field is required.Health is first and foremost self responsibility and no medical or holistic treatment can give any guarantees or warranties. The Puna health Spa members declare staff and practitioners immune from prosecution or censure by any authority, person or entity, insofar as they are acting within the above stated principles and precepts. Any possible concerns will first be discussed with Dr. Frederik Martin and the Puna Health Spa will be adequately supportive in finding full resolution, following guidelines given by the NZDSOS medical society.
Yes, I agree
17
What is/are your (oral) health issues? Please give details and history:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
Diagnose* This field is required.What are your most obvious symptoms?
Very reactive to temperature
I feel / see a swelling
Pain with biting only
Pain all the time
Sharp edge
Loose / broken tooth
Toxic filling(s)
Other
19
To make sure How to take photos of your teeth: use the instructions in this video for the next question to take 5 photos
20
Secure upload for x-rays and scans and photo's (encrypted). It is very important that you provide us with any dental x-rays made in the last 5 years, dentist should provide you copies per email Please upload files here when available (please let them sent copies to your email)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
When possible and you are using a smartphone to fill this in, please ask someone to take 5 photo's of the teeth (position your teeth in the sun or spotlight, use fingers in the corner at the site of the issue to open lips), click on the button here to shoot or upload later at the end of the questionnaire
22
Is there pain? (no pain slide to right or max pain slide to left)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
23
Last dental visit* This field is required.When was your last visit to a dentist or a hygienist approximately
within last 3 months
within last 3 months - 6 months
within 6 months - 1 year
between 1 year- 5 years
More than 5 years
24
Regular dentistry* This field is required.If you have not been to see a dentist regularly, what is the reason? (multiple answers possible)
Bad experience
Fear
Money
other
25
Have ever had dental complications during or after treatment, like no numbing, allergic reactions, anxiety, swallowing issues, bleeding or other? When not please fill in: no.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
26
Cosmetics* This field is required.Are you happy with the overall appearance of your smile? Use slider for smiley happy or not.
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
27
Chewing function alright* This field is required.Are you able to chew all kinds of food easily?
YESNO
28
Appearance/ breath issues* This field is required.Have others recently commented about your teeth or breath?
YESNO
29
How is your average stress level in the last two months?* This field is required.This is a smiley slider, go left for high stress, go right for super relaxed
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
30
Anesthetic issues* This field is required.Have you ever had an unfavorable reaction to anesthetic? (local or full)
YESNO
31
Saliva Flow low* This field is required.Do you have a dry mouth during the day and or an acidic taste in your mouth?
YESNO
32
Bleeding gums, periodontal issues* This field is required.Have you experienced bleeding of gums when cleaning your teeth or do you know you had/have periodontitis?
YESNO
33
Teeth grinding noticed* This field is required.Are you aware of grinding or clenching your teeth?
YESNO
34
How would you say is your level of anxiety with dental treatment?* This field is required. Slide left for high and slide right for pretty relaxed
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
35
How would you describe your diet?* This field is required.Multiple answers possible
More then 50% processed pre made food
More then 50% unprocessed or self cooked
Mainly Organic or home grown
Vegetarian or Vegan (or mainly)
Other
Open to suggestions to improve nutrition
36
Chest pain noticed* This field is required.Do you experience chest pain with strenuous exercise?
YESNO
37
Having Heart conditions* This field is required.Do you have any of the following conditions?(none: go to the end)
Heart attack
irregular heart beat/ arrhythmia
cardiovascular problems
Heart surgery- stents, bypass
None of the above
38
Hyperventilation noticed* This field is required.Do you or did you ever hyperventilate?
YESNO
39
Fainting during treatment* This field is required.Did you ever faint during a medical or dental treatment?
YESNO
40
Systemic conditions you have* This field is required.Please indicate the systemic conditions you may have? (none: go to the end)
High blood pressure
Stroke/ paralysis
Epilepsy
Asthma/ lung problem
Diabetes
Thyroid diseases
Kidney disease
Anemia
no systemic condition
41
Having Hay fever/ sinus problems* This field is required.Do you have sinus problems or hay fever
YESNO
42
Gastric Problem* This field is required.Do you have gastric problems with loss of weight of more than 5kg?
YESNO
43
Digestion* This field is required.Please indicate any digestive problems
Diarrhea for longer periods
Constipation frequently
Bowel pains
Bloating
No digestive problems
44
Malignant * This field is required.Do you have a malignant lymphatic or blood disease?
YESNO
45
Bleeding disorder* This field is required.Do you experience excessive bleeding from treatment or at any other time?
YESNO
46
Radiotherapy* This field is required.Have you had radiotherapy on your head and neck in the last 10 years? (Not x-rays)
YESNO
47
Contagious diseases* This field is required.Do you have a contagious disease?
YESNO
48
COVID 19* This field is required.Here are the questions on COVID 19. Please tick the ones that apply to you. .
I am pro choice (to choose to not have vaccinations, including this choice for healthcare workers)
I was coerced to get vaccinated, but do not want any more
I question the mainstream epidemic narrative
I believe the mainstream epidemic narrative
49
Vaccinations, inoculations, novel virus injections* This field is required.Please tick the ones that apply to you. .
I have had vaccinations in my childhood
I have had one or more vaccinations before 2019 as an adult
I have had the basic Covid injections
I have had one or more booster Covid injections
I never had vaccinations or Covid injections
I have had other vaccinations since 2019 (like flu or tetanus etc.)
I am not sure what I have been injected
50
Please list all the medication and or supplements that you are using?* This field is required.Please write "none" or "do not know" when applicable
Huge
Large
Normal
Small
Ok
Ok
51
Please give a concise overview of your medical - health life history* This field is required. Approximate year of accidents, surgeries, treatments, start of chronic illness, major life events linking to health issues (moving house, work / study trouble, issues with parents, children or partner, issues from childhood). When you already have this digital then you can also upload it at the secure upload for x-rays below). Please also list your current GP and or other healthcare workers that give you support or treatment.
Huge
Large
Normal
Small
Ok
Ok
52
New Member Introductory Conversation (included in membership)Online or phone introductory conversation for new members to discuss issues and possible holistic solutions that are available as selfcare or at Puna Spa and other NZDSOS healing accommodators. Highly recommended for those living outside Marlborough NZ to prevent unnecessary travel costs. If you use this, then we need color pictures of your teeth as explained.
53
Choice of donation* This field is required.Please describe your choice, you can pay online directly after you have sent this form
I would like to use cash on the day
I pay with bank now
I pay with credit card now
I pay with crypto now
I wish a special gift arrangement
Should be Empty: