Heath questionnaire

Health Questionnaire

Height, weight, date of birth?
Blood pressure?
Basal temperature? Measure it as soon as you wake up, without too much movement beforehand.
How many bowel movements do you have per day?
How many bowel movements do you have per week?
What does your daily diet consist of? Be as honest as possible and be aware of all the foods you consume. This is a very important part.
Do you have cold hands or feet?
Do you lose hair?
Is it easy for you to gain weight and hard to lose it?
Are your nails weak, with many white lines and waves?
Do you have or have you ever had hemorrhoids?
Do you have muscle cramps?
Do you have irregular heartbeats usually or sometimes?
Do you have heart problems?
Do you have headaches or migraines?
Do you have or have you ever had a hernia?
Have you ever had an aneurysm?
Do you have osteoporosis?
Do you have scoliosis?
Do you get easily irritated?
Do you usually have low energy?
Do you have symptoms of depression?
Do you perhaps have low calcium in blood tests?
Have you ever had problems with your spine or discs in your back?
Has anyone in your family had Hashimoto’s or Reidel’s disease?
Do you sweat a lot, moderately, or barely at all?
Do you have panic attacks?
Are you very shy or do you feel inferior to others?
Do you have shortness of breath or difficulty breathing deeply?
Do you have arrhythmia?
Do you have trouble sleeping?
Do you feel chronic fatigue?
Do you get tired easily?
Do you have weak lower back?
Do you have high cholesterol?
Do you have or have you ever had sciatica?
Do you have arthritis?
Have doctors told you that you have any other disease ending in -itis?
When did your health problems and general problems start? Write as many details as possible about when, how, and what was happening in your life during those periods, any changes, important events, shocks, traumas, and similar.
Do you have gas after meals?
Do you feel like food stays in your stomach?
Do you get acid reflux or perhaps have reflux?
Do you see completely undigested food in your stool?
Are you thin and find it hard to gain weight?
Does food just pass through you (diarrhea)?
Do you have many moles on your body?
Are you overweight?
Do you have multiple sclerosis, Parkinson’s, or paralysis?
Do you have tremors, restless legs?
Do you generally have high or low blood pressure?
Do you have hypoglycemia (low blood sugar)?
Do you have diabetes? Type 1 or 2?
Do you have tinnitus (ringing in the ears)?
Have you ever been diagnosed with Addison’s disease or adrenal hyperplasia?
Do you have low steroids or cortisol?
Have you been diagnosed with autism?
Have you been diagnosed with ADD or ADHD?
Do you have gastritis or enteritis?
Is your tongue coated with a white, yellow, green, or brown film, especially when you wake up?
Do you have gastroparesis?
Do you have a hiatal hernia?
Do you have colitis?
Do you have diverticulitis?
Do you often have diarrhea?
Do you have constipation, or only sometimes?
Have you ever had ulcers in your stomach or intestines?
Do you have or have you ever had any gastrointestinal cancer (stomach, intestinal, rectal)? If yes, explain.
Do you have Crohn’s disease?
Do you have problems with gas? Or other GI (glycemic index) problems?
Do you have problems digesting fats?
Does fatty or dairy food cause bloating and/or pain in the stomach area?
Is your stool white or very light brown in color?
Do you have pain exactly in the middle of your back (especially when you eat)?
Do you have pain behind the lower right part of your rib?
Do you have liver or brown spots on your skin (not freckles)?
Do you have yellowish parts of skin or eyes?
Do you have any skin changes in pigmentation?
Have you ever had anemia?
Do you have or have you ever had hepatitis? If yes, which type: A, B, C, autoimmune?
Do you consume alcohol? How often?
Do you have chest pain or angina?
Have you ever had a heart attack?
Have you ever had heart surgery?
Do you have heart arrhythmia? If yes, what kind?
Do you ever feel pressure in your chest?
Have you ever had, or do you have stabbing pains anywhere, especially around the heart area?
Do you have or have you ever had high blood pressure?
Do you have a pacemaker or stent?
Do you have or get eczema?
Do you have skin deficiencies anywhere?
Do you have dermatitis or rashes?
Do you have psoriasis?
Does it itch somewhere? If yes, where?
Is your skin dry?
Is your skin oily?
Do you get or have dandruff in your hair?
Do you have any other skin problems? If yes, what kind?
Do you have tattoos? If yes, where and how much of your body is covered with it? When did you get the tattoo?
Do you lose hair, are you bald, or balding?
Have you ever had lymph nodes removed? If yes, where and how many?
Do you have gray hair?
Do you have memory difficulties?
Do you often get cold and flu symptoms?
Do you have fibromyalgia or scleroderma?
Do you have sinus problems?
Do you often have sore throats?
Do you have swollen or tense lymph nodes?
Do you have or have you ever had a tumor? If yes, where? Was it benign or malignant?
Do you have low platelets in your blood?
Have you ever had an appendicitis? If yes, when?
Do you get cysts, pimples, acne, boils, and similar?
Do you exercise regularly? How many times a week? What type of training?
Have you ever had a purulent boil?
Have you ever had toxemia?
Do you have or have you ever had cellulitis? (not cellulite, this is different!) Cellulite is dimpled skin caused by fatty deposits. Cellulitis is a painful skin infection that happens when bacteria enter a break in your skin.
Have you ever had gout?
Do you sometimes have blurry vision?
Do you have mucus in your eyes when you wake up in the morning?
Do you snore in your sleep?
Do you have sleep apnea?
Have you had your tonsils removed? When?
Have you ever had a urinary tract infection?
Have you ever had a burning sensation during urination?
Do you have problems with urine retention?
Have you ever had kidney stones?
Do you have under-eye circles (especially in the morning)?
Is your urine flow interrupted or do you have difficulty urinating?
Do you get cramps or pain on either side from mid to lower back?
Do you have or have you ever had nephritis?
Do you have weak lower back or trouble with it?
Do you have or have you ever had sciatica?
Do you have or have you ever had bladder inflammation?
Do you have or have you ever had bronchitis?
Do you have or have you ever had emphysema?
Do you have or have you ever had asthma?
Do you have or have you ever had chronic obstructive pulmonary disease (COPD)?
Do you have an inhaler or nebulizer? How often? What medication? What is your oxygen saturation?
Do you have pain when you breathe?
Do you have pain when you take a deep breath?
Is it difficult for you to take a deep breath?
Do you have or have you ever had lung cancer? If yes, when?
Do you have or have you ever had a collapsed lung? If yes, when?
Do you smoke? How often? How many packs or cigarettes per day?
Have you ever had pneumonia? When and how often?
Have you ever worked near toxic chemicals, in mines, or near asbestos?
Do you often cough?
**Do you cough up mucus when you cough? What color is the mucus? (clear, yellow, green, brown, or black)?**
Are you vaccinated?
Have you received vaccines when traveling to other countries?
Have you received flu vaccines?
Do you have amalgam fillings?
Have you been exposed to nuclear waste or by-products, heavy metals, or chemicals?
Have you ever had radiation or chemotherapy? If yes, how many treatments?
Have you ever used any recreational drugs? (this information is confidential and is used solely to help you achieve optimal health) If yes, what drugs? Do you still use them?
Do you use chemical medications or have you used them? If yes, which ones, how often, when, how long, and for what reasons?
Do you use natural supplements? If yes, which ones, how often, when, how long, and for what reasons?
Do you have allergies? If yes, what are you allergic to?
Have you had surgeries during your life? If yes, which ones and when?
Genetic/family history – any health problems or diseases that have run in your family for generations?
What are your biggest health problems or concerns? Write down any problem or symptom you have/feel that is not already answered here in the questionnaire.

For Women Only:
Do you have irregular periods?
Do you have heavy bleeding during menstruation?
Do you have or have you had ovarian cysts? When exactly?
Do you have or have you had fibroids in the uterus? When?
Do you have or have you had endometriosis or atypical cells? Which exactly?
Do you have or have you had fibrocystic breasts? When?
Do you feel breast pain during menstruation?
Do you have low or high sexual desire?
Have you had a hysterectomy? Was it partial or total?
Were any other organs removed at the same time (e.g., gallbladder), if yes, which organs?
Have you ever had an abortion? If yes, date?
Have you ever had a miscarriage? When?
Have you had difficulty getting pregnant in the past or recently?
Have you been on contraceptive pills? How long?
Are you currently pregnant?

For Men Only:
Do you have prostate inflammation? (very frequent urination, especially at night), if yes, how often do you urinate?
Do you have prostate cancer? What is your PSA (prostate-specific antigen) number and when was it?
Do you have testicular hypertrophy?
Do you have low or high sexual desire?
Do you have erection problems?
Do you have premature ejaculation? Or similar issues?