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Health Questionnaire:
A Self-Assessment
THEHEALINGJUNCTION.CA
#THERAWRESET
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Personal Information
Date Completed:
MM
/
DD
/
YYYY
Name:
Your answer
Gender:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
Height (ft.)
Your answer
Weight (lbs)
Your answer
Address:
Your answer
City:
Your answer
State / Province:
Your answer
Zip / Postal Code:
Your answer
Email:
Your answer
Country:
Your answer
Cell Phone:
Your answer
I have used herbal tinctures before:
Yes
No
Clear selection
Family Physician:
Yes. The information is listed below.
No. I do not have a family physician.
Clear selection
Physician Information:
Your answer
Vitals Information
If you are not sure of your vital sign readings you may leave them blank.
Eye Color:
Your answer
Blood Pressure (Right Side):
Your answer
Blood Pressure (Left Side):
Your answer
Pulse:
Your answer
Respirations:
Your answer
Basal Temp. (F):
Your answer
pH (specify urine or saliva):
Your answer
How many bowel movements do you have per day?
Your answer
How often do you move your bowels per week?
Your answer
What does your current diet consist of? Be honest!
Your answer
THYROID (GLANDULAR SYSTEM)
Do you get cold hands / feet?
Yes
No
Clear selection
Do you feel cold or have a hard time getting warm?
Yes
No
Clear selection
Are you cold, but burning inside?
Yes
No
Clear selection
Is it easy to put on weight and hard to lose it?
Yes
No
Clear selection
Do you have irregular heartbeat?
Yes
No
Clear selection
Do you get headaches or migraines?
Yes
No
Clear selection
Do you become irritable easy?
Yes
No
Clear selection
Do you have low energy levels?
Yes
No
Clear selection
Do you have, or have you ever had, a goiter?
Yes
No
Clear selection
Have you or a family member been diagnosed with
Hashimoto
disease?
Yes
No
Yes (family member)
Yes (me)
Clear selection
Have you or a family member been diagnosed with
Reidel
disease?
Yes
No
Yes (family member)
Yes (me)
Clear selection
How much do you sweat?
Low
Medium
Excessive
Clear selection
PARATHYROID (GLANDULAR SYSTEM)
Are your finger nails ...
ridged
brittle
weak
Do you have varicose or spider veins?
Yes
No
Do you have, or have you had ...
hemorrhoids
prolapsed organs
Do you experience cramping in your muscles?
Yes
No
Is your bladder ...
strong
weak
Have you ever had a hernia?
Yes
No
Have you ever had an aneurysm?
Yes
No
Do you have osteoporosis and / or score low on your bone density tests?
Yes
No
Do you have scoliosis?
Yes
No
Do you suffer from symptoms of depression?
Yes
No
Do you suffer from any other mental illness?
Yes
No
If you answered yes above, which mental illness?
Your answer
Do your tests come back showing low Calcium levels?
Yes
No
Do you have spine deterioration, herniated discs or bone spurs?
Yes
No
Do your legs get tired or cramp after you walk?
Yes
No
Do you bruise easily?
Yes
No
PACREASE
Do you get gas after you eat?
Yes
No
Do you feel your foods just sitting in your stomach?
Yes
No
Do you have Acid Reflux?
Yes
No
Do you see any undigested foods in your stools?
Yes
No
Are you thin and have a hard time putting on weight?
Yes
No
Do your foods pass right through you (diarrhea)?
Yes
No
Do you have moles on your body? (Adrenal & Pancreatic weakness)
Yes
No
ADRENAL GLANDS (GLANDULAR SYSTEM)
Are you overweight?
Yes
No
Clear selection
Do you have ...
M.S.
Parkinson's
Palsy
Clear selection
Do you have anxiety attacks or feel overly anxious?
Yes
No
Clear selection
Do you feel excessive shyness or inferior to others?
Yes
No
Clear selection
Do you have tremors. nervous legs, etc.?
Yes
No
Clear selection
Do you have ...
High Blood Pressure
Low Blood Pressure
Clear selection
Do you have hypoglycaemia (low blood sugar)?
Yes
No
Clear selection
Do you have diabetes (high blood sugar)?
Yes
Type I
Type II
No
Clear selection
Do you have tinnitus (ringing in the ears)?
Yes
No
Clear selection
Do you have S.O.B (shortness of breath) or is it hard to take a deep breath?
Yes
No
Clear selection
Do you have heart arrhythmias?
Yes
No
Clear selection
Do you have a hard time sleeping or insomnia? (pineal)
Yes
No
Clear selection
Do you have Chronic Fatigue Syndrome?
Yes
No
Clear selection
Have you ever been diagnosed with ...
Addison's disease
Congenital Adrenal Hyperplasia
Clear selection
Do you have elevated blood cholesterol levels?
Yes
No
Clear selection
Do you have arthritis, bursitis or any other inflammatory issues?
Yes
No
Clear selection
Do you have any 'itis's' (inflammatory conditions)?
Yes
No
Clear selection
Do you have low steroid or cortisol levels?
Yes
No
Clear selection
Have you been diagnosed with Autism?
Yes
No
Clear selection
Have you been diagnosed with ADD (attention deficit disorder) or ADHD (attention deficit hyperactivity disorder)?
Yes
No
Clear selection
FEMALES ONLY
Are your menstruation cycles irregular?
Yes
No
Clear selection
Do you have excessive bleeding during menstruation?
Yes
No
Clear selection
Do you have or have you had ovarian cysts?
Yes
No
Clear selection
If you answered yes to the above (cysts), when?
Your answer
Do you have or have you had fibroids?
Yes
No
Clear selection
If you answered yes to the above (fibroids), when?
Your answer
Do you have or have you had endometriosis or A-typical cells?
Yes
No
Clear selection
If you answered yes to the above, which ones?
Your answer
Do you have or have you had fibrocystic breasts?
Yes
No
Clear selection
If you answered yes to the above (fibrocystic breasts), when?
Your answer
Do you get sore breasts, especially during menstruation?
Yes
No
Clear selection
Do you have low or excessive sex drive?
Yes
No
Clear selection
Have you had a hysterectomy?
Yes
No
Clear selection
If you answered yes to the above (hysterectomy), was it ...
partial
complete
Clear selection
Have you had any other organs removed?
Yes
No
Clear selection
If you answered yes to the above (organs removed), which organs?
Your answer
Have you had a D&C?
Yes
No
Clear selection
If you answered yes to the above (D&C), when?
Your answer
Have you had a miscarriage?
Yes
No
Clear selection
If you answered yes to the above (miscarriage), when?
Your answer
Have you had difficulty conceiving children ...
In the past
recently
Clear selection
Have you been on Birth Control pills?
Yes
No
Clear selection
If you answered yes to the above (Birth Control), for how long?
Your answer
Are you currently pregnant?
Yes
No
Clear selection
MALES ONLY
Do you have prostatitis (frequent urination esp. at night)?
Yes
No
Clear selection
Do you have prostate cancer?
Yes
No
Clear selection
If you answered yes to the above (prostate cancer), What are you PSA counts? Dates?
Your answer
Do you have testicular hypertrophy (enlargement)?
Yes
No
Clear selection
Do you have low or excessive sex drive?
Yes
No
Clear selection
Do you have erection problems?
Yes
No
Clear selection
Do you have premature ejaculation?
Yes
No
Other:
Clear selection
GASTRO-INTESTINAL TRACT
Do you have gastritis or enteritis?
Yes
No
Clear selection
Is your tongue coated (white, yellow, green or brown), especially in the morning?
Yes
No
Clear selection
Do you have gastroparesis?
Yes
No
Clear selection
Do you have a Hiatus Hernia?
Yes
No
Clear selection
Do you have Colitis?
Yes
No
Clear selection
Do you have Diverticulitis?
Yes
No
Clear selection
Do you get or have diarrhea?
Yes
No
Clear selection
Do you get or have constipation?
Yes
No
Clear selection
Have you ever had stomach or intestinal ulcers?
Yes
No
Clear selection
Do you have or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal etc.)
Yes
No
Other:
Clear selection
Do you have Crohn's disease?
Yes
No
Clear selection
Do you have 'gas' problems?
Yes
No
Other:
Clear selection
LIVER | GALBLADDER | BLOOD
Do you have problems digesting fats?
Yes
No
Clear selection
Do fats or dairy foods cause bloating and / or pain in the stomach area?
Yes
No
Clear selection
Are your stools white, or very light brown in color?
Yes
No
Clear selection
Do you get pain in the middle of your back (especially after eating)?
Yes
No
Clear selection
Do you get pain behind the right lower rib area?
Yes
No
Clear selection
Do you have 'liver' or brown spots on your skin? (not freckles)
Yes
No
Clear selection
Are you Jaundiced (yellowing of the skin) or eyes?
Yes
No
Clear selection
Do you have skin pigmentation changes?
Yes
No
Clear selection
Are you or have you ever been anemic?
Yes
No
Other:
Clear selection
Do you have or have you ever had hepatitis?
Yes
No
Clear selection
If you answered yes to the above (hepatitis), which one?
A
B
C
Clear selection
Do you consume alcohol regularly? How Often?
Yes
No
Other:
Clear selection
HEART + CIRCULATION
Do you get chest pains or angina?
Yes
No
Other:
Clear selection
Have you ever had a heart attack (Myocardial Infarction)?
Yes
No
Clear selection
Have you ever had open-heart surgery?
Yes
No
Clear selection
Do you have heart arrhythmia's? What kind?
Yes
No
Other:
Clear selection
Do you ever feel pressure on your chest?
Yes
No
Clear selection
Do you get 'prickly' pains anywhere, especially in the heart area? Where?
Yes
No
Where?
Other:
Clear selection
Do you have or have you ever had High Blood Pressure? (kidneys)
Yes
No
Clear selection
Do you have? ...
pacemaker
stents
Clear selection
SKIN
Do you get or have skin rashes?
Yes
No
Clear selection
Do you get skin blemishes?
Yes
No
Clear selection
Do you have Eczema?
Yes
No
Clear selection
Do you have Dermatitis?
Yes
No
Clear selection
Do you have Psoriasis?
Yes
No
Clear selection
Do you itch anywhere?
Yes
No
If so where?
Other:
Clear selection
Is your skin dry?
Yes
No
Clear selection
Is your skin excessively oily?
Yes
No
Clear selection
Do you have dandruff?
Yes
No
Clear selection
Do have any other skin problems?
Yes
No
Maybe
Where?
Other:
Clear selection
Do you have any tattoos?
Yes
No
Maybe
If so where?
and how much of your body is covered (0 - 100%)?
Other:
Clear selection
What is the approximate date of the most recent tattoo?
MM
/
DD
/
YYYY
LYMPHATIC SYSTEM
Do you have hair loss or are you bald or going bald?
Yes
No
Other:
Clear selection
Have you ever had lymph nodes removed?
Yes
No
Where and how many?
Other:
Clear selection
Do you have grey hair?
Yes
No
Clear selection
Do you have a hard time remembering things?
Yes
No
Clear selection
Do you ever get colds or flu-like symptoms?
Yes
No
Clear selection
Do you have fibromyalgia or scleroderma?
Yes
No
Clear selection
Do you have sinus problems?
Yes
No
Clear selection
Do you have or get a sore throat?
Yes
No
Clear selection
Do you have swollen lymph nodes?
Yes
No
Clear selection
Do you have or have you had tumors?
Yes
No
If yes, where?
Other:
Clear selection
If you answered yes to the above (tumors), which type?
fatty
benign
malignant
Clear selection
Do you have a low blood platelet count?
Yes
No
Clear selection
Have you had appendicitis or an appendectomy?
Yes
No
If yes, when?
Other:
Clear selection
Do you get boils, pimples, cysts etc.?
Yes
No
Clear selection
Do you get regular exercise?
Yes
No
How many times per week?
and what type of exercise?
Other:
Clear selection
Have you ever had abscesses?
Yes
No
Clear selection
Have you ever had toxemia?
Yes
No
Clear selection
Do you have or have you had cellulitis? (not cellulite, this is different)
Yes
No
Clear selection
Have you ever had gout?
Yes
No
Clear selection
Do you get blurred vision?
Yes
No
Clear selection
Do you have mucus in your eyes when you wake up in the morning?
Yes
No
Clear selection
Do you snore?
Yes
No
Clear selection
Do you have sleep apnea?
Yes
No
Clear selection
Have you had your tonsils out?
Yes
No
What age?
Other:
Clear selection
KIDNEYS | BLADDER
Have you ever had a urinary tract infection (UTI's)?
Yes
No
Clear selection
Have you ever had 'burning' upon urination?
Yes
No
Clear selection
Do you have problems holding your bladder? (parathyroid)
Yes
No
Clear selection
Have you ever had kidney stones?
Yes
No
Clear selection
Do you have bags under your eyes (esp. in the morning)?
Yes
No
Clear selection
Is your urine flow restricted?
Yes
No
Clear selection
Do you get cramping or pain on either side of your mid-to-lower back?
Yes
No
Clear selection
Do you or did you ever have nephritis?
Yes
No
Clear selection
Do you have lower back weakness?
Yes
No
Clear selection
Do you have or have you had sciatica?
Yes
No
Clear selection
Do you or did you ever have cystitis?
Yes
No
Clear selection
LUNGS
Do you get or have you had bronchitis?
Yes
No
Clear selection
Do you get or have you had emphysema?
Yes
No
Clear selection
Do you get you have you had asthma?
Yes
No
Clear selection
Do you get or have you had C.O.P.D?
Yes
No
Clear selection
Are you on inhalers or nebulizers? How often?
Yes
No
Other:
Clear selection
Your oxygen saturation level is ....
Your answer
Do you have pain when you breathe?
Yes
No
Clear selection
Do you have pain when you take a deep breath?
Yes
No
Clear selection
Have you ever been diagnosed with lung cancer?
Yes
No
When?
Other:
Clear selection
Do you or did you ever have a collapsed lung?
Yes
No
When?
Other:
Clear selection
Do you smoke? If yes, how often? How many per week?
Yes
No
Other:
Clear selection
Have you ever had pneumonia? When and how often?
Yes
No
Other:
Clear selection
Have you ever worked around toxic chemicals, in coal mines or around asbestos?
Yes
No
Other:
Clear selection
Do you cough a lot?
Yes
No
Clear selection
Do you remove any mucus when you cough? If yes, is it clear, yellow, green brown or black?
Yes
No
Other:
Clear selection
ENVIRONMENTAL + OTHER TOXINS
Have you been vaccinated?
Yes
No
Other:
Clear selection
Have you had shots for traveling to foreign countries?
Yes
No
Other:
Clear selection
Have you had Flu shots?
Yes
No
Clear selection
Do you have mercury Amalgams?
Yes
No
Clear selection
Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?
Yes
No
Other:
Clear selection
Have you had ? ...
radiation
chemotherapy & if so how many treatments?
Other:
Clear selection
Have you ever used any form of recreational drugs? (this information is confidential and used to help you obtain optimal health only!)
Yes
No
If yes, which ones? and do you currently use them?
Clear selection
CHEMICAL MEDICATIONS
List any medications you are currently taking and the reason for taking them
Your answer
NATURAL SUPPLEMENTS
List any natural supplements you are taking
Your answer
ALLERGIES
List anything that you are allergic to
Your answer
PAST SURGERIES
List any surgeries you have had, minor and major along with the year
Your answer
GENETIC | FAMILY HISTORY
List the health issues - if known - of each family member
Your answer
WHAT ARE YOUR MAJOR HEALTH COMPLAINTS OR CONCERNS?
Please list any conditions or symptoms that were not already covered in this questionnaire
Your answer
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