HEALTH QUESTIONNAIRE Basic Information Please complete every question to the best of your ability. Take note that drop down question/answers will default to top answer, so make sure you are selecting the right answer for every question. Today's Date: Name: Street Address: City: State: ZIP: Birth Date: Age: Gender: Male Female Other Height: Weight: Section 1: Lifestyle & Habits How many hours of sleep do you get each night? Do you exercise? No Daily Weekly Monthly What form of exercise? Do you smoke cigars? If yes, how many and how often? Do you smoke cigarettes? If yes, how many and how long? Do you use recreational drugs? If yes, which ones? Are you currently using any medications? If yes, which ones? Are you currently taking vitamins/minerals/herbs? If yes, which ones and for what purpose? Section 2: Dietary Habits Do you eat breakfast? Every day 3-6 days a week 1-2 days a week Rarely Do you eat your heaviest meal at noon? Do you drink coffee? How many cups/day? (Caffeinated or Decaf) Do you drink tea? (Hot or Iced) How many cups/day? Do you drink soda pop? If yes, how much? (Decaf or Diet) Do you drink alcoholic beverages? How much and how often? (Beer, Wine, Liquor) Do you add salt to your food? (Light, Medium, Heavy) Do you crave any foods? Which ones? Do you drink water? How many glasses/day? Size of water glass? What kind of water? (Tap, Filtered, Reverse Osmosis, Alkaline, etc.) Poor appetite: Yes No Crave sweets or coffee - Feel shaky when hungry - Irritable before meals: Yes No Do these foods upset you? (Raw cabbage, Cole slaw, Onions, Green peppers, Cucumbers, Radishes, Rich foods, Greasy foods, Spicy foods, etc.) Section 3: Stress, Work, and Sitting Habits How would you rate your stress level on a scale of 1-5? What type of work do you do? How many hours per day do you sit? Section 4: Symptom Checklist Overweight: Coughing blood: Chronic fever: Yes No Rectal itching: Yes No Itching of the nose: Yes No Motion sickness: Yes No Seizures: Yes No Forgetful (long-term memory): Yes No Absent-minded (short-term memory): Yes No Head tilts to one side... Right? Left? Headaches: If yes, what part of head do they originate? Hair dull (lacking sheen): Yes No Eyes bulging/protruding... Both? Right? Left? Dimness of vision. Have cataracts? Which eye? Both? Blindness or glass eye... Both? Right? Left? Gums receding: Yes No Teeth glassy on the ends? Rough edges? Cavities or fillings (Few/Many)? Tongue coated: Yes No Tongue dry: Yes No Tongue hot: Yes No Athlete’s foot: Yes No Numbness of hands or feet? Which? Cold hands or feet? Which? Fingernails: Split? Brittle? Rough? Soft? Ridges? Skin abnormally colored? Oily? Dry? Psoriasis? Burning urination: Yes No Urine lost its force? Difficult to start or stop? Wake at night to urinate. Times per night? Times per week? Bowel movements. Times per day? Times per week? Abnormal stool consistency: Hard? Soft? Loose? Pain with bowel movements? Yes No Blood in stool: Yes No Muscular pains: Yes No Do muscular pains move or travel from one area of the body to another? Pain in bladder area: Yes No Pain in joints: Yes No Pain in legs: Yes No Pain in lower back (especially after prolonged sitting or riding): Yes No Chest pains: Yes No Pain in left arm: Yes No Insomnia? Sleep soundly? Wake up tired? Sluggish in the morning: Yes No Cold most of the time: Yes No Tendency to anemia: Yes No Nausea: Yes No Section 5: Bowel & Urine Patterns Do you have to get up at night to urinate? How many times per night? Do you tend toward polyuria (frequent urination with large volume)? Do you tend toward constipation? Do you tend toward diarrhea? Do you see undigested food in your stools? On average, what is the color of your stools? Pale Light brown Dark brown Green Other Section 6: Health Goals What are two or three topics, issues, or conditions you would be most interested in improving or better understanding? Section 8: Gender-Specific Health Male: Do you have prostate trouble? Male: Lump(s) in testicle? Female: Do you have painful periods? Female: Do you experience menstrual cramps? Female: Do you experience hot flashes? Female: Are you on birth control pills? IUD? If yes, how long? Female: Do you have regular or irregular periods? Section 9: Additional Health Questions Do you have or have you ever had asthma? Do you have allergies? Do you have your gallbladder? Do you have your appendix? Do you suffer from headaches? How frequent? What part of your head? Is your stool light, medium, or dark in color? Do you wake up before the alarm or do you like to hit the snooze? When was the last time you had your cholesterol tested? Was it high? Were your triglycerides high? Have you had your Vitamin-D levels checked? What was it? Section 10: Photos Please upload photos of your supplements. You can also upload photos of yourself, including a full body shot, close-up of your eyes, fingernails, tongue, or any other abnormalities. Consent I understand that I am responsible for my own health and healthcare choices. Date: Sign/Print Name: