HEALTH QUESTIONNAIRE A SELF-ASSESSMENT

CLIENT INFORMATION
Name: Wt. Ht. M\F : Address: e-mail address: eye color: cell phone:

Please check Yes or No. Add comments as necessary. Thyroid/Parathyroid (Glandular System
Do you have low energy levels? Do you suffer from symptoms of epress!on? Do you get !rr!ta"le eas!ly? Is !t easy to put on we!ght an har to loose !t? Do you get #ol han s an $or feet? Do you get #ramp!ng !n your mus#les? Do you sweat profusely or hardly at all? Do you have% or have you ever had% a go!ter? Do you have an !rregular heart"eat? Do you have M!tral &alve 'rolapse (Heart Murmur)? Do you get hea a#hes or m!gra!nes? *ave you ever ha an aneurysm? Do your la" tests #ome "a#+ show!ng low #al#!um levels? D! you s#ore low on your "one ens!ty tests? Do you have osteoporos!s? Do you have spi e deterioratio or her iated dis!s? Do you have s#ol!os!s?

Are your f!ngerna!ls r! ge % "r!ttle or wea+? Do you have hair loss or are you "ald or #oi # "ald?

Do you have% or have you ever had a hern!a? Do you have% or have you ever had hemorrho! s? Do you have var!#ose or sp! er ve!ns?

Adrenal Glands (Glandular System)

*ave you ever "een !agnose w!th Addiso $s %isease or w!th &o #e ital Adre al Hyperplasia? Do you have Chron!# Fat!gue ,yn rome? Do you get t!re eas!ly? Do you have low "loo pressure (belo !!" systolic)? Do you have elevate "loo #holesterol levels? Do you have an#iety attacks% or feel o$erly an#ious% Do you have a har t!me sleep!ng? Do you have tremors% nervous legs% et#-? Do you have heart arrhythm!as? Do you have shortness o& breath% an $or !s !t har to ta+e a eep "reath? Do you have arthritis or "ursitis? Do you have lower "a#+ wea+ness? Do you have% or have you ever had% s#!at!#a?

Females Only
Are your menstruat!on.s !rregular? Do you get e/#ess!ve "lee !ng ur!ng menstruat!on? Do you have or have you ha ovar!an #ysts? Do you have or have you ha f!"ro! s? Do you have or have you ha en ometr!os!s or A0typ!#al #ells? Do you have or have you ha f!"ro#yst!# "reasts? Do you get sore "reasts% espe#!ally ur!ng menstruat!on? Do you have a low or e/#ess!ve se/ r!ve? *ave you ha a hystere#tomy? Date? 'art!al or #omplete? *ave you ha a D 1 C? Date? *ave you ha a m!s#arr!age? *ave you ha !ff!#ulty #on#e!v!ng #h!l ren? *ave you "een on 2!rth Control '!lls? For how long? Are you #urrently pregnant?

Males Only
Do you have prostat!t!s (&re'uent urination esp. at ni(ht)? If yes% how often? Do you have prostate #an#er? ',A #ount3s4 Do you have test!#ular hypertrophy ( enlar(ement)? Do you have a lo' or e(!essive se/ r!ve? Do you have ere#t!on pro"lems? Do you have premature e5a#ulat!on?

Pancreas
Do you have D!a"etes (Hi(h )lood *u(ar)? Type I or Type II Do you have hypogly#em!a (+o )lood *u(ar)? Do you see any un !geste foo s !n your stools? Do you feel your foo s 5ust s!tt!ng !n your stoma#h?

Do you have a#! reflu/? Do you get gas after you eat? Are you th!n an have a har t!me putt!ng on we!ght? Do your foo s pass r!ght through you ( !arrhea)? Do you have #astritis or e teritis? Do you have moles on your "o y?

Skin
Do you get or have s+!n rashes? Do you get s+!n "lem!shes? Do you have E!)e*a or %er*atitis? Do you have 'sor!as!s? Do you !t#h anywhere? 6here? Is your s+!n ry? Is your s+!n e/#ess!vely o!ly? Do you get or have an ruff?

Gastro-Intestinal Tract
Is your tongue #oate ( hite, yello , (reen or bro n)% espe#!ally !n the morn!ng? *ow often o you have a 2owel Movement? Do you have 7gas8 pro"lems? Do you get or have Const!pat!on? Do you get or have D!arrhea? *ave you ever ha stoma#h or !ntest!nal ul#ers? Do you have +astritis% E teritis% &olitis or %iverti!ulitis? Do you or have you ever ha any type of gastro0!ntest!nal #an#ers4 Sto*a!h% !olo % re!tal% et#? 'lease spe#!fy4 Do you have Crohn3s D!sease? Other 9I pro"lems4

Li er/Gall!ladder/"lood
Do you have% or have you ever ha % hepat!t!s? A% ,% or & Do you have a pro"lem !gest!ng fats? Do fats or a!ry foo s #ause "loat!ng an $or pa!n !n the stoma#h area? Are your stools wh!te or very l!ght "rown !n #olor? Do you get pa!n !n the m! le of your "a#+ ( especially a&ter eatin()? Do you get pa!n "eh!n the r!ght% lower r!" area? Do you have 7l!ver8 or "rown spots on your s+!n? ( not &reckles) Do you have any s+!n p!gmentat!on #hanges? Do you have s+!n pro"lems? If so% what type? Are you anem!#?

#eart $ %irculation
Do you have% or have you ever had *!gh 2loo 'ressure? :our average 2loo 'ressure !s ;;;;;; over ;;;;Do you ever feel pressure on your #hest? Do you get !hest pai s or a #i a? Do you have heart arrhythm!as? *ave you ever ha a heart atta#+ (Myocardial -n&arction)? Do you have a heart murmur or M!tral &alve 'rolapse? *ave you ever ha open0heart surgery? 6hat +!n ? Do you get 7pr!#+ly8 pa!ns anywhere% espe#!ally !n the heart area? 6here? Do you "ru!se eas!ly? Do your legs get t!re or #ramp after you wal+? Do you have any gray ha!r? Do you have a har t!me remem"er!ng th!ngs?

Lym&hatic System
Do you have or have you ha tumors? 6here? 6hat type? Fatty- ,e i# or &a !erous Is your !mmune system wea+ or slugg!sh? *ave you ha your tons!ls out? 6hat age? *ave you ha appe di!itis or an appe de!to*y? 6hen? *ave you ever ha to/em!a? *ave you ever ha gout? *ave you ever ha any lymph no es remove ? 6here? *ow many? *ave you ever ha a"s#esses? Do you snore? Do you have% or have you ever had% #ellul!t!s? Do you have swollen lymph no es? Do you have sleep apnea? Do you have s!nus pro"lems? Do you have mu#us !n your eyes when you wa+e up !n the morn!ng? Do you have allerg!es? Do you have a sore throat or #et sore throats ofte ? Do you have a low platelet #ount ("loo )?

Do you get "oils% pi*ples% an the l!+e? Do you get "lurre v!s!on? Do you ever get #ol s or flu0l!+e symptoms? Are you allerg!# to anyth!ng? 'lease ,pe#!fy4

'idneys $ "ladder
*ave you ever ha a ur!nary tra#t !nfe#t!on (<TI3s)? *ave you ever e/per!en#e 7"urn!ng8 upon ur!nat!on? Do you have pro"lems hol !ng your "la er? *ave you ever ha +! ney stones? Do you have "ags un er your eyes (esp. in the mornin()? Is your ur!ne flow restr!#te ? Do you get #ramp!ng or pa!n on e!ther s! e of your m! 0to0lower "a#+? Do you have or have you ever had nephr!t!s? Do you have or have you ever had #yst!t!s?

Lun(s
Do you have or have you ever had "ron#h!t!s? 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 C-O-'-D? Are you on !nhalers or ne"ul!=ers? *ow often? 6hat type? Do you +now what your o/ygen saturat!on !s? Do you get pa!n when you "reathe? Do you get pa!n when you ta+e a eep "reath? Do you have or have you ever had lung #an#er? Do you have a #ollapse lung? Are you a smo+er? *ow often? *ave you ever ha pneumon!a? *ave you ever wor+e aroun to/!# #hem!#als% !n #oal0m!nes or aroun as"estos? Do you #ough a lot? Do you get any mu#us when you #ough? 6hat #olor !s the mu#us?

)n ironmental To*ins
*ave you "een va##!nate ? *ave you ha shots for travel!ng to fore!gn #ountr!es? *ave you ha Flu shots? Do you have mer#ury Amalgams? Do you f!n !t !ff!#ult to ta+e eep "reaths? *ave you "een e/pose to nu#ear waste or "y0pro u#ts% heavy metals or #hem!#als? *ave you ha ra !at!on or #hemotherapy? If so% how many treatments?

.hat are your *ai health !o*plai ts or !o !er s/

'lease l!st an ela"orate on any #on !t!ons or symptoms that th!s >uest!onna!re has not #overe or as+e you-

%hemical Medications - Please list any chemical medications that you are presently takin( and hat they.re prescribed &or:

Sur#eries 0 'lease l!st any past surger!es you have ha (e.(. tonsils remo$ed, hysterectomies, open heart sur(ery, etc./:

+atural Su&&lements - Please list any natural supplements you are currently takin(:

Aller#ies Genetic #istory,

Mom4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; Da 4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; (Maternal) 9ran father4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; (Maternal) 9ran mother4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; (Fraternal) 9ran father4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; (Fraternal) 9ran mother4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; ,!ster4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; ,!ster4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;

2rother4 ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;