Signs & Symptoms Questionnaire

Sign and Symptoms Questionnaire

First Name

Last Name

Date of Birth

Gender

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone no.

Occupation

Job Title

GP/ Specialist name

Phone/Mobile

PART I:

Read the following questions and select the number that applies.

KEY: Leave blank (0) = Do not consume or use

1 = Consume or use 2-3 times/month

2 = Consume or use weekly

3 = Consume or use daily

Section 1 - Diet & Lifestyle

Section II

Medications: Indicate any medications you’re currently taking or have taken in the last 12 months (0 = no, 2 = yes):

	No	Yes
25. Antacids
26. Antianxiety meds
27. Antibiotics
28. Anticonvulsants
29. Antidepressants
30. Anti-inflammatories
31. Aspirin/Ibuprofen
32. Asthma inhalers
33. Beta blockers
34. Birth control pill or implant contraceptives

	No	Yes
35. Chemotherapy
36. Cholesterol lowering
37. Cortisone/steroids
38. Diabetic medication
39. Diuretics
40. Estrogen or progesterone (synthetic)
41. Estrogen or progesterone (natural)
42. Heart medication
43. High Blood Pressure

	No	Yes
44. Laxatives
45. Recreational drugs
46. Relaxants/Sleeping pills
47. Testosterone (natural or synthetic)
48. Thyroid medication
49. Paracetamol/acetaminophenRadiation exposure (0=no, 1=yes)
50. Ulcer medications
51. Viagra/Sidenafal citrate

Other medications and dosages (if known):

PART II

Read the following questions for each section and select the number that applies.

Section 1 – Upper Gastrointestinal System

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
52. Belching or gas within 1 hr. of eating
53. Heartburn or acid reflux
54. Bloating shortly after eating
55. Vegan diet (no dairy, meat, fish, eggs) (0=no, 1=yes)
56. Bad breath (halitosis)
57. Loss of taste for meat
58. Sweat has a strong odor
59. Stomach upset by taking vitamins
60. Sense of excess fullness after meals
61. Feel like skipping breakfast

	0	1	2	3
62. Feel better if you don’t eat
63. Sleepy after meals
64. Fingernails chip, peel or break easily
65. Anemia unresponsive to iron
66. Stomach pains or cramps
67. Diarrhea, chronic
68. Diarrhea shortly after meals
69. Black or tarry coloured stools
70. Undigested food in stool

Section 2 – Liver and Gallbladder

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
71. Pain between shoulder blades
72. Stomach upset by greasy foods
73. Greasy or shiny stools
74. Nausea
75. Sea, car or airplane sickness, motion sickness
76. History of morning sickness (0=no, 1=yes)
77. Light or clay coloured stools
78. Dry skin, itchy feet and/or skin peels on feet
79. Headache over the eyes
80. Gallbladder attacks (0=never, 1=years ago, 2=within last year, 3=within last 3 months
81. Gallbladder removed (0=no, 1=yes)
82. Bitter taste in mouth, especially after meals
83. Become sick if drinking wine (0=no, 1=yes)
84. If drinking wine, easily intoxicated (0=no, 1=yes)

	0	1	2	3
85. Easily hung over if you were to drink wine (0=no, 1=yes)
86. Alcohol per week (0 = <3, 1 = <7, 2 = 14) 87. Recovering alcoholic (0=no, 1=yes)
87. Recovering alcoholic (0=no, 1=yes)
88. History of drug or alcohol abuse (0=no, 1=yes)
89. History of hepatitis (0=no, 1=yes)
90. Prescription/Recreational drugs used long-term (0=no, 1=yes)
91. Sensitive to chemicals (perfume, cleaning solvents, insecticides, exhaust, etc.)
92. Sensitive to tobacco smoke
93. Exposure to diesel fumes
94. Pain under right side of rib cage
95. Haemorrhoids or varicose veins
96. Aspartame (Nutrasweet) consumption
97. Sensitive to aspartame (Nutrasweet)
98. Chronic Fatigue or Fibromyalgia

Section 3 – Small Intestine

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
99. Food allergies
100. Abdominal bloating 1 to 2 hours after eating
101. Specific foods make you tired or bloated (0=no, 1=yes)
102. Pulse speeds after eating
103. Airborne allergies
104. Experience hives
105. Sinus congestion, "stuffy head"
106. Crave bread or noodles
107. Alternating constipation and diarrhea

	0	1	2	3
108. Crohn's disease (0=no, 1=yes in the past, 2=currently mild condition, 3=severe)
109. Wheat or grain sensitivity
110. Dairy sensitivity
111. Are there foods you could not give up (0=no, 1=yes)
112. Asthma, sinus infections, stuffy nose
113. Bizarre vivid dreams or nightmares
114. Use over-the-counter pain medications
115. Feel spacey or unreal

Section 4 – Large Intestine

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
116. Anus itches
117. Coated tongue
118. Feel worse in moldy or musty place
119. Taken any antibiotic for a total accumulated time of (0=never, 1 = <1 month, 2 = 3 months)
120. Fungus or yeast infections
121. Ring worm, "jock itch", "athletes foot", nail fungus
122. Yeast symptoms increase with sugar, starch or alcohol
123. Stools hard or difficult to pass
124. History of parasites (0=no, 1=yes)
125. Less than one bowel movement per day

	0	1	2	3
126. Stools have corners or edges, are flat or ribbon shaped
127. Stools are not well formed (loose)
128. Irritable bowel or mucus colitis
129. Painful to press along outer sides of thighs (Iliotibial Band)
130. Mucus in stool
131. Excessive foul smelling lower bowel gas
132. Bad breath or strong body odors
133. Blood in Stool
134. Cramping in lower abdominal region
135. Dark circles under eyes

Section 5 – Mineral Needs

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
136. History of Carpal Tunnel Syndrome (0=no, 1=yes)
137. History of lower right abdominal pain or ileocecal valve problems (0=no, 1=yes)
138. History of stress fractures(0=no, 1=yes)
139. Bone loss (reduced density on bone scan)
140. Are you shorter than you used to be? (0=no, 1=yes)
141. Calf, foot or toe cramps at rest
142. Cold sores, fever blisters or herpes lesions
143. Frequent fevers
144. Frequent skin rashes and / or hives
145. Have you ever had a herniated disc? (0=no, 1=yes)
146. Excessively flexible joints, "double jointed"
147. Joints pop or click
148. Pain or swelling in joints
149. Bursitis or tendonitis

	0	1	2	3
150. History of bone spurs (0=no, 1=yes)
151. Morning stiffness
152. Vomiting or nausea
153. Crave chocolate
154. Feet have a strong odor
155. History of anemia
156. Whites of eyes (sclera) blue tinted
157. Hoarseness
158. Difficulty swallowing
159. Lump in throat
160. Dry mouth, eyes and / or nose
161. Gag easily
162. White spots on fingernails
163. Cuts heal slowly and / or scar easily
164. Decreased sense of taste or smell

Section 6 – Essential Fatty Acids

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
165.Aspirin is an effective pain reliever (0=no, 1=yes)
166. Crave fatty or greasy foods
167. Low or reduced fat diet (0=never, 1=years ago, 2=within past year, 3=currently)
168.Tension headaches at base of skull

Section 7 – Sugar Handling

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
173. Awaken a few hours after falling asleep, hard to get back to sleep
174. Crave sweets
175. Binge or uncontrolled eating
176.Excessive appetite
177. Crave coffee or sugar in the afternoon
178. Sleepy in afternoon
179.Fatigue that is relieved by eating

	0	1	2	3
180. Family members with diabetes (0 = none, 1 = 1 or 2, 2 = 3 or 4, 3 = more than 4)
181. Headache if meals are skipped or delayed
182. Irritable before meals
183.Shaky if meals delayed
184. Frequent thirst
185. Frequent urination

Section 8 – Vitamin Need

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
186. Muscles become easily fatigued
187. Feel exhausted or sore after moderate exercise
188. Vulnerable to insect bites
189. Loss of muscle tone, heaviness in arms / legs
190. Enlarged heart or congestive heart failure
191. Pulse below 65 beats per minute at rest (0=no, 1=yes)
192. Ringing in the ears (Tinnitus)
193. Numbness, tingling or itching in hands and feet
194. Depressed
195. Fear of impending doom
196. Worrier, apprehensive, anxious
197. Nervous or agitated
198. Feelings of insecurity
199.Heart races

	0	1	2	3
200. Can hear heart beat on pillow at night
201. Whole body or limb jerk as falling asleep
202. Night sweats
203. Restless leg syndrome
204. Cheilosis (cracks at corner of mouth)
205. Fragile skin, easily chaffed, as in shaving
206. Bleeding gums especially when brushing teeth
207. MSG sensitivity
208. Wake up without remembering dreams 209. Small bumps on back of arms
209. Small bumps on back of arms
210. Strong light at night irritates eyes
211. Nose bleeds and/or tend to bruise easily
212. Polyps or warts

Section 9 – Adrenal

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
213.Tend to be a "night person"
214. Difficulty falling asleep
215. Slow starter in the morning
216. Keyed up, trouble calming down
217. Blood pressure above 120/80
218. Headache after exercising
219. Feeling wired or jittery after drinking coffee
220. Clench or grind teeth
221. Calm on the outside, troubled on the inside
222. Chronic low back pain, worse with fatigue
223. Become dizzy when standing up suddenly
224. Difficult maintaining manipulative correction
225.Pain after manipulative correction

	0	1	2	3
226. Arthritic tendencies 227. Crave salty foods
227. Crave salty foods
228. Salt foods before tasting
229. Perspire easily
230. Chronic fatigue, or get drowsy often
231. Afternoon yawning
232. Afternoon headache (inner) side of the knee
233. Asthma, wheezing or difficulty breathing
234. Pain on the medial
235.Tendency to sprain ankles or get "shin splints"
236.Tendency to need to wear sunglasses
237. Allergies and / or hives
238.Weakness, dizziness

Section 10 – Pituitary

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
239.Height over 6' 6" (1m 98cm) (0=no, 1=yes)
240. Early sexual development (before age 10) (0=no, 1=yes)
241. Increased libido
242. Splitting type headache
243. Memory failing
244. Feel fine when eating sugar (0=no, 1=yes)
245. Delayed (after age 13) sexual development (0=no, 1=yes)

Section 11 – Thyroid

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
252. Sensitive/allergic to iodine
253. Difficulty gaining weight, even with large appetite
254. Nervous, emotional, can't work under pressure
255. Inward trembling
256. Flush easily
257. Fast pulse at rest
258. Intolerance to high temperatures
259. Difficulty losing weight

	0	1	2	3
260. Mentally sluggish, reduced initiative
261. Easily fatigued, sleepy during the day
262. Sensitive to cold, poor circulation (cold hands and feet)
263. Constipation, chronic
264. Excessive hair loss and/or coarse hair
265. Morning headaches, wear off during the day
266. Loss of lateral 1/3 of eyebrow
267. Seasonal sadness

Section 12 – Men Only

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

Section 13 – Women Only

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
277. Depression during periods
278. Mood swings associated with periods (PMS)
279. Crave chocolate around periods
280. Breast tenderness associated with cycle
281. Excessive menstrual flow
282. Scanty blood flow during periods
283. Occasional skipped periods
284. Variations in menstrual cycles
285. Endometriosis
286. Uterine fibroids

	0	1	2	3
287. Breast fibroids, benign masses
288. Painful intercourse (dyspareunia)
289. Vaginal discharge
290. Vaginal dryness
291. Vaginal itchiness
292. Gain weight around hips, thighs and buttocks
293. Excess facial or body hair
294. Hot flushes
295. Night sweats (in menopausal females)
296.Thinning skin

Section 14 – Cardiovascular

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
297. Aware of heavy and / or irregular breathing
298. Discomfort at high altitudes
299. "Air hunger" and / or yawn frequently
300. Compelled to open windows in a closed room
301. Shortness of breath with moderate exertion

	0	1	2	3
302. Dull pain or tightness in chest and / or radiate into right arm, worse with exertion
303. Cough at night
304. Blush or face turns red for no reason
305. Ankles swell, especially at end of day
306. Muscle cramps with exertion

Section 15 – Kidney and Bladder

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

Section 16 – Immune system

KEY: Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

	0	1	2	3
312.Runny or drippy nose
313. Catch colds at the beginning of winter
314. Mucus producing cough
315. Frequent colds or flu (0 = 1 or less/year, 1 = 2 to 3/year, 2 = 4 to 5/year, 3 = 6 + /year)
316. Other Infections (sinus, ear, lung, skin, bladder, kidney etc.) (0 = 1 or less/year, 1 = 2 to 3/year, 2 = 4 to 5/year, 3 = 6 + per year)

	0	1	2	3
317. Never get sick (0 = sick only 1 to 2 times in last 2 years, 1 = not sick in last 2 years, 2 = not sick in last 4 years, 3 = not sick in last 7 years)
318. History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue, Hepatitis or other chronic viral condition (0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe)
319.Acne (adult)
320. Itchy skin / dermatitis
321. Cysts, boils, rashes

Health Assessment Questionnaire Disclaimer:

By completing this questionnaire, I acknowledge the following:

1. Accuracy of Information: I confirm that all information provided is accurate and true to the best of my knowledge.
2. Purpose of Questionnaire: I understand that this questionnaire is for assessment purposes only and does not establish a practitioner-client relationship or any commitment to work together.
3. Non-Substitute for Medical Advice: I recognize that any insights or recommendations provided are for informational purposes and are not a replacement for medical advice from a qualified healthcare provider.
4. Personalized Guidance: I understand that any guidance received is tailored to my individual answers and may not apply to others.

I acknowledge the above and consent to have this website store my submitted information so they can respond to my inquiry.

	0	1	2	3
1. Alcohol
2. Artificial sweeteners
3. Candy, desserts, refined sugar
4. Carbonated beverages
6. Chewing tobacco
7. Cigarettes
8. Cigars/pipes

	0	1	2	3
8. Caffeinated drinks
9. Fast foods
10. Fried Foods
11. Luncheon meats/hot dogs
12. Margarine
12. Milk products
13. Refined flour/baked goods

	0	1	2	3
15. Vitamins and minerals
16. Herbs for weight control
17. Water, distilled
18. Water, tap
19. Water, well
20. Radiation exposure (0=no, 1=yes)

	0	1	2	3
169. Headaches when out in the hot sun
170. Sunburn easily or suffer sun poisoning
171. Muscles easily fatigued
172. Dry flaky skin and or dandruff

	0	1	2	3
246. Decreased libido
247. Excessive thirst
248. Weight gain around hips or waist
249. Menstrual disorders
250. Under 4' 10" (Mature height)
251. Tendency to ulcers or colitis