Health Questionaires. A Self Assessment.

Surname:

First name:

Initials:

Title:

Date of birth:

Address:

Telephone numbers:

Email address:

Living environment: Rural–Suburban–Commercial–Industrial.

Work environment: Rural–Suburban–Commercial–Industrial.

Nature of Work:

Physical Activity at work: None–Mild–Moderate–High.

Stress at Work: Little–Mild–Moderate–High.

Boredom at Work: Rate from 1-10 with ten being the highest level of boredom

Height:

Weight:

Resting Pulse Rate:

Blood Pressure: Systolic:              Diastolic:       Left and Right:

Medication: current and ever in the past. Dosage. How long did or have you been using the medication.

  • antibiotics
  • antidepressants
  • antidiarrhoea
  • anti uric acid/gout drugs
  • antihypertension
  • antinausea
  • appetite suppressants-diet pills
  • diuretics
  • laxatives
  • tranquilizers
  • cortisone/steroids
  • Aids medication.
  • analgesics-pain killers.
  • anti angina meds
  • anticoagulents
  • antihistamines
  • hormones.
  • cholesterol meds.
  • anti-inflammatories.
  • anti spasmodics.
  • expectorants
  • oral contraceptives.
  • others………………………………………………………

Smoking and Alcohol: Daily amounts-

Supplements,Herbs,Homeopathics and other nutrients:

  • What/which ones.
  • For how long
  • Dosage

Family History: Genetics-parents, grandparents and siblings:

Do any of your close blood relatives have or have they ever had any of the following conditions:

  • cancer
  • osteoporosis
  • multiple sclerosis
  • heart disease
  • diabetes
  • senility
  • arthritis
  • overweight
  • allergies
  • depression
  • other mental/emotional problems

other……………………………….

Family Doctor:

What has your GP done about your current health problems?

Basal Temperature:

pH: both urine and saliva

When was your last medical checkup? Results?

Allergies: list anything that you are allergic to:

Past Surgeries:list any major or minor surgery–what it was and when it was performed and why.

What are your Health Problems at present?

 

 

Why are you here? What are you concerned about and or seeking to fix?

 

What are your expectations regarding your  health from The Wholistic Health Centre? In other words, “How can I help you? What would you like to achieve?”

 

 

 

 

 

Balancing the Systems of the Body:

To experience optimum whole body health from a nutritional standpoint, we balance the systems of the body. Here are system questionaires for each of the systems of the body. Check the areas of symptomatic difficulty you are presently experiencing. This information can serve as an indicator of which systems in your body require attention in  order to improve your health. When one system is out of balance, it affects the other systems. When one or more systems are weak, the other systems have to pick up the slack and become overworked. It is very important to take inventory of your body to see where your weaknesses are. Some of your complaints are hereditary. Forewarned is forearmed ! Weak areas require more attention and strengthening. In Traditional Chinese Medicine, if you have a chronic illness of any kind, a balancing principle must be applied. This means balancing or regenerating the body’s systems. This differs from medicine, because it has nothing to do with treating disease. Allopathic medicine first names a disease and then seeks a specific cure for it. Like the Chinese system, the Naturopathic and Nutritional approach does not subscribe to specific diseases, only internal weaknesses that manifest in certain symptom patterns. We use the symptom pattern to discern the weakness and then strengthen the body system. This creates optimal conditions that allow the symptoms to go away because the vitality of the body has triumphed. Try to shift your thinking from disease orientation, which seeks an external cure to a specific disease or symptom, to strengthening and balancing your body. Symptoms are only signs of possible weakness. Vitamins, herbs and supplements do not heal anything. Your body has the innate ability to heal itself. Natural supplements support the body and strengthen the weak areas. The body then gets on with inner healing which is its job.

Gastrointestinal Questionnaire:

Candida,Yeast and Fungus:

  • Chronic fatigue,especially after eating.
  • Depression.
  • Recurrent digestive complaints.
  • Constipation or diarrhoea.
  • Foul smelling stools.
  • Bloatedness with or without lots of gas.
  • Rectal itching.
  • Food and/or environmental allergies.
  • Severe PMS.
  • Feel spacey.
  • Foggy headedness or find it hard to concentrate.
  • Poor memory.
  • Severe mood swings.
  • Anxiety/nervousness.
  • Restless sleep.
  • Recurrent or chronic fungal infections ( athlete’s foot, nail fungus, ringworm, crotch itch).
  • Extreme chemical sensitivity.
  • Cannot tolerate perfumes or smoke.
  • Coated or sore tongue.
  • Prostatitis
  • Recurrent vaginal or urinary infections.
  • Lightheadedness or feel drunk after minimal wine, beer or certain foods
  • Respiratory problems
  • Chronic skin rashes or acne.
  • Loss of libido/impotence.
  • Thrush (white fungus in mouth or vagina).
  • Headaches/migraines.
  • Muscle and joint pains.
  • Low blood sugar.
  • History of frequent antibiotic use or massive doses at any point in time. Allergic to any antibiotics.
  • Taking or have taken birth control pills
  • Crave sugar, breads or alcoholic beverages.
  • Endometriosis and/or infertility.
  • Above conditions get worse in moldy places like basements or damp climates.
  • Above conditions get worse after eating or drinking items that contain yeast or sugar.

Parasites /Worms:

  • Fatigue.
  • Depression.
  • Anxiety, nervousness and/or irritability.
  • High blood pressure.
  • Increased susceptibility to infections.
  • Headaches.
  • Digestive problems ( colic, nausea, pain)
  • Numbness/tingling/tremors.
  • Skin problems ( rashes, eczema, psoriasis)
  • Learning disabilities.
  • Ringing in the ears.
  • Muscle and joint pain.
  • Allergies/asthma.
  • Kidney and/or liver problems
  • Constipation.
  • Memory problems.
  • Anaemia.
  • Weight loss-unexplained.
  • Big change in your appetite pattern.
  • Varied symptoms with no relief.
  • Worms or parasites visible in your stool.

Digestive Function:

General Digestion:

  • Gastritis or enteritis.
  • Gastroparesis.
  • Hiatus hernia.
  • Colitis.
  • Diverticulitis.
  • Diarrhoea or constipation.
  • Stomach  or intestinal ulcers.
  • Gastro-intestinal cancers.
  • Crohn’s Disease.
  • Gas problems.

Hypoacidity:

  • Frequent heartburn.
  • Abdomen bloats after eating.
  • Excessive upper or lower abdominal gas 2-3 hours after eating.
  • Indigestion 2-3 hours after eating.
  • Vomiting of undigested food.
  • Loss of taste for meat.
  • Belching or burping after meals.
  • Frequent upset stomach.
  • Known food allergies.
  • Fasting affects your stomach.
  • Coated tongue.
  • Treated for anaemia many times without success.
  • Frequent constipation and/or diarrhoea.
  • Told that you have a B12 or folic acid deficiency.

 

Hyperacidity:

  • Chronic burning sensation in the stomach.
  • Stomach pains just before meals.
  • Spicy food or caffeine causes diarrhoea.
  • Acute stomach pain after eating or lying down.
  • Stomach pains relieved by drinking milk/cream.
  • Take antacids frequently.
  • Stomach complaints aggravated by worry or tension.
  • Frequent meals relieve your stomach pains.
  • Diagnosed with an ulcer.
  • Experience sudden, acute indigestion.
  • Pains subside when on holiday or relaxed.
  • History of gastritis or ulcers.
  • Stool is black when you are not taking an iron supplement.
  • Excessive use of aspirin and other anti-inflammatory medications.

Pancreas/Small Intestine:

  • Lower bowel gas several hours after eating.
  • Bloating after meals.
  • Acid reflux.
  • Feels like your food is just sitting in your stomach.
  • Your food passes right through you.(diarrhoea)
  • Fibrous foods and roughage cause constipation.
  • Stools are shiny and/or poorly formed.
  • Undigested foods in your stools.
  • Difficult to gain weight. Battling always being thin.
  • Skin is dry and flaky.
  • Experience diarrhoea frequently.
  • Fibre irritates your diarrhoea.
  • Hair is brittle and dry.
  • Alternate between diarrhoea and constipation.
  • Known food allergies.
  • Frequent stomach cramps.
  • Mucous in your stools.
  • Pain on inside of left shoulder blade.
  • Pain on left side of of abdomen (lower rib cage)
  • Pass large amounts of foul-smelling stool.
  • Problems with acne.
  • Low self esteem.
  • Moles on your body (adrenal and pancreatic weakness)

Liver/Gallbladder:

  • Fatigue.
  • Constipation.
  • Yellow in the whites of your eyes.
  • Jaundiced-yellowing of the skin. Ever had hepatitis.
  • Frequent belching/burping.
  • Exposure to toxic chemicals/drugs/alcohol.
  • Chemical sensitivities.
  • Abdominal cramps.
  • Stools are white or very light brown colored and foul smelling.
  • Consistent bloating and gas.
  • Bad breath(halitosis) and/or body odour.
  • Eye problems.
  • Dry skin or hair.
  • Bitter, metallic taste in mouth in mornings.
  • Painful bowel movements.
  • Skin on your feet peels.
  • Pain in the middle of your back especially after eating.
  • Pain in right shoulder blade.
  • Pain radiating down outside of your legs.
  • Pain on the right side of your abdomen behind lower rib cage.
  • Frequent bad dreams/nightmares.
  • Fatty foods cause nausea and distress and/or are hard to digest.
  • Chronic anger, frustration and/or irritability.
  • Wake regularly between 01.00 and 03.00am
  • Red blood present in your stool.
  • Triglyceride level above 115.
  • Cholesterol level above 200
  • High LDL, low HDL cholesterol.
  • Diagnosed with hepatitis/jaundice
  • History of gallbladder attacks or gallstones.
  • Liver or brown spots on your skin (not freckles).
  • Skin pigmentation changes.
  • Colon Health:

  • Frequent diarrhoea with no apparent cause.
  • Bowel movements thin and pencil like.
  • History of constipation.
  • Painful bowel movements.
  • Excess gas and flatulence.
  • Abdominal pain and tenderness.
  • History of vaginal yeast infections.
  • History of antibiotic use.
  • Mucus in your stool.
  • Blood in your stool.
  • Alternating constipation and diarrhoea.
  • Suffer from anxiety or depression.
  • Frequently sick with a cold or infection.
  • Capillary Fragility:

  • Do you have hemorrhoids spider and/or varicose veins.
  • Prolapsed organs.
  • Do you bruise easily.(can also be parathyroid)
  • Do you have itching, burning pain and/or inflammation in the rectal area?
  • Do you have bright red blood on the toilet roll/ paper after a bowel movement

    Cardiovascular Questionnaire:

    Heart Health:

  • Chest pain radiating to left arm and/or left side of the neck.
  • Angina.
  • Aneurism.
  • Heart attack.(myocardial infarction)
  • Open heart surgery or heart bypass or stent.
  • Pacemaker.
  • Prickly pains in the heart area.
  • Arrhythmia.
  • Heart murmer or mitral valve prolapse.
  • Frequent leg cramps especially after a long walk. Intermittant claudication.
  • Dizziness.
  • Heartburn.
  • Breathing Difficulties.
  • Pressure on your chest.
  • Minor exercise causes exhaustion.
  • Feel anxious or uptight frequently.
  • Feet and ankles swell.
  • Heart sometimes flip flops in the chest.
  • Hacking cough.
  • Diagonal crease in earlobe.
  • High blood pressure.
  • Rapid heartbeat(more than 90 beats/minute).
  • Diagnosed with a heart condition.

Circulation:

  • Fingers and toes are often cold/blue.
  • Extremities often fall asleep.
  • Ankles swell during the afternoon.
  • Out of breath after light exertion.
  • Difficult to breathe when lying down.
  • Numbness/heaviness in arms and/or legs.
  • Nose and/or face have tiny spider veins.
  • Frequent tingling sensation in legs/fingers.
  • Frequent cramps in legs when walking.
  • Difficulty concentrating.
  • Frequent headaches.
  • Frequent ringing in your ears

Blood Pressure:

  • Diagnosed with high blood pressure (greater than 140/90 mm/Hg)
  • Frequent headaches.
  • Dizziness.
  • Often fatigued.
  • Difficulty breathing.
  • Insomnia.
  • Suffer from restlessness or emotional instability.
  • Intestinal complaints.

Respiratory/Lung Function:

  • Chronic cough.
  • Do you get mucous when you cough. What colour is the mucous-clear,yellow,green, or black.
  • Emphysema
  • C.O.P.D.
  • Breathing difficulties.
  • Do you use inhalers or nebulizers. How often and what type.
  • Your oxygen saturation level is….
  • Chest pains when you breathe
  • Pain when you take a deep breath.(adrenals)
  • Difficult to take a deep breath
  • Lung cancer.
  • Ever had a collapsed lung.
  • Wheezing.
  • Diagnosed with asthma.
  • History of bronchitis.
  • Recurrent sinus infections.
  • Hypersensitive to environmental pollutants.
  • Excessive mucus in throat and nose.
  • Frequent sore throat.
  • Work around chemicals/pollutants/radiation/asbestos/coal or gold mines.
  • Chronic pain around rib cage.
  • Smoker.How often.How many cigarettes per day.
  • Ever had pneumonia.
  • Coughing up blood.

Genito-Urinary Function:

Bladder Health:

  • Burning and pain on urination.
  • Increased urinary frequency and urgency.
  • Problems holding your bladder eg when laughing.
  • Lower abdominal pain.
  • Recurrent bladder infections.
  • Tend to pass urine when you cough or sneeze
  • Urinary incontinence ( can’t hold urine back eg when jumping on mini trampoline or skipping).
  • Wake up frequently at night to urinate.
  • Tendency to drip after urinating.
  • Foul smelling or dark urine.
  • Cystitis.
  • History of bladder infections. UTI’s
  • History of antibiotic use for bladder infections.

Kidney Health:

  • Low or mid back pain or cramping on either side (near lower rib cage).
  • Cloudy urine.
  • Foul smelling and/or strong smelling urine.
  • Fever/chills.
  • Nausea/vomiting.
  • Fatigue around 4pm.
  • Ankle oedema or pitting oedema.
  • Unknown fears.
  • History of antibiotic use for urinary tract infections.
  • History of kidney infections.
  • Is your urine flow restricted.
  • Blood in urine.
  • Kidney stones.
  • Nephritis.
  • Low back weakness.
  • Sciatica.
  • Bags under your eyes, especially in the morning.

Eye Health:

  • Experience any visual problems
  • Night blindness
  • Cloudy vision.
  • Discharge from your eyes.
  • Pain, swelling or redness of your eyes
  • Diagnosed with any eye disorder (cataracts, glaucoma, macular degeneration, etc.)

Ear Health:

  • General ear pain.
  • Earache.
  • Red, swollen eardrum.
  • Dull, throbbing pain in ear.
  • Ringing in ears.
  • Static sounds in ears.
  • Current ear infection.

Endocrine Questionnaire:

Adrenal Exhaustion:

  • Get dizzy when you stand up quickly.
  • Lose your vision when you stand quickly.
  • Weak and shaky often.Tremors.Nervous legs.
  • Heart arrhythmias.
  • Sensitive to bright light, sunlight or headlights.
  • Crave salt.
  • Low blood pressure or high blood pressure.
  • Overweight.
  • Headache when standing up.
  • Sensitive to environmental pollutants.
  • Lump in the throat that hurts when upset.
  • Have allergies (hay fever, asthma, rashes, etc.)
  • Heavy stress causes complete exhaustion.
  • Easily startled or frightened.
  • Loud noises cause your heart to pound.
  • Form goose bumps easily.
  • Perfectionist.
  • Dark circles under the eyes.
  • Difficult time breathing.Shortness of breath or hard to take a deep breath.
  • Low steriods or cortisol levels
  • Inflammatory conditions.”itis”.Arthritis, bursitis, rheumatoid arthritis, colitis, enteritis, phlebitis, neuritis, etc.
  • Elevated blood cholesterol levels.
  • Addisons Disease or Congenital Adrenal Hyperplasia
  • Chronic Fatigue Syndrome.
  • Insomnia. (can also be the pineal gland).
  • Tinnitis (ringing in the ears)
  • Diabetes (high blood sugar).
  • Hypoglycemia.(low blood sugar)
  • Excessive shyness or feel inferior to others.
  • Anxiety attacks or feel overly anxious.

Parathyroid:

  • Do you have spine deterioration, herniated discs or bone spurs.
  • Do your legs get tired or cramp after a long walk.
  • Do you bruise easily.
  • Do your tests come back showing low Calcium levels.
  • Do you score low on your bone density levels.
  • Do you have scoliosis.
  • Do you have osteoporosis.
  • Fingernails ridged, brittle or weak.
  • Cramping in muscles.

Thyroid:

Hypothyroid:

  • Experience chronic fatigue.
  • Gain weight easily. Battle to lose it.
  • Goiter.
  • Family history of thyroid problems.
  • Outer third of your eyebrows thinning or sparse.
  • Family history of autoimmune disease.
  • Family history of celiac disease or gluten sensitive.
  • Been exposed to radiation treatments or dental xrays.
  • Sensitive to cold weather.
  • Easily depressed.
  • Slow heart rate.
  • Low blood pressure.
  • Swollen eyes of face.
  • Chronic constipation.
  • Varicose or spider veins, hemorrhiods or prolapsed organs(parathyroid as well)
  • Dry flaky skin.
  • Easily irritated.
  • Slowed or slurred speech.
  • Excess hair loss.
  • Hair and/or nails are brittle and dry.
  • Recurrent infections.
  • Allergic reactions.
  • Headaches.
  • Heavy menstrual flow.
  • Suffer from PMS.
  • Painful periods.
  • Low sex drive.
  • Difficulty concentrating or remembering.
  • Cry easily.
  • Difficulty sleeping.
  •  Cold hands and feet.
  • Ancillary temperature below 36.4*C
  • Irregular heartbeat.
  • Low energy levels.
  • Drink chlorinated or flouridated water.

Hyperthyroid:

  • Rapid heartbeat.(more than 90 beats/minute.)
  • Bulging, swollen eyes.
  • Sweat excessively with moist skin and palms.
  • Increased appetite.
  • Chest pains.
  • Gastrointestinal disturbances.
  • Difficulties relaxing.
  • Insomnia.
  • Menstrual problems.
  • Rash or swelling in front of lower leg.
  • Diarrhoea.
  • Enlarged thyroid (goiter)
  • Experience tremors (trembling).
  • Increased body temperature.
  • Fatigue.
  • Anxious and nervous.
  • Low tolerance to heat.
  • Lose weight easily.

Hypoglycemia:

  • Crave sweets or sugar in some form, eat it, get a temporary boost of energy and mood and later come crashing down.
  • Irritable, anxious, tired, jittery, or headachy during the day.Feel temporarily better after eating.Shaky 2-3 hours after a meal.
  • Fatigued if meal is missed.
  • Hungry for sweets. Can get heart palpitations from sugar/sweets.
  • Family history of hypoglycemia or alcoholism.
  • History of polycystic ovarian syndrome or infertility.
  • Family history of high blood pressure.
  • Symptoms occur in afternoon or several hours after eating.
  • If I eat carbs for breakfast, I can’t seem to control my eating for the rest of the day.
  • Memory problems and/or poor concentration.
  • Wake up at night feeling hungry.
  • Digestive complaints.
  • Headaches relieved by sweets or alcohol.
  • I have gut fat.
  • I get night sweats.
  • Eating makes me calm.
  • Anxiety/nervousness/anxious/impatient.
  • Go for the breadbasket at a restaurant.
  • Rapid heart rate.
  • Extreme hunger.
  • Weak/shaky/jittery.
  • Irritable,weak, tired  if meal is missed.
  • Dizzy when standing too quickly.
  • Double vision.
  • Feel drugged and sleepy after eating carbohydrates.
  • Cannot stop eating sweets or carbs once I start.
  • Family history of heat disease.
  • Family history of type 2 diabetes
  • Chronic fungal infections.

Hyperglycemia. Sugar Sabotage:

  • Irritable
  • Frequent urination.
  • Weakness or fatigue.
  • Unusual hunger.
  • Excessive thirst.
  • Nausea/vomiting.
  • Cuts that will not heal.
  • Vision problems.
  • History of diabetes in your family.
  • Overweight.
  • Tingling/numbness in feet.
  • Skin infections/leg sores.

Pituitary Health:

  • Abdominal bloating.
  • Redness and bloating of face.
  • Fatigue.
  • Overweight at the hips/waist (pear shaped)
  • Menstrual irregularities.
  • Lack of menstruation in younger girls.
  • Water retention/oedema.
  • Thyroid problems.
  • Slowed growth in children.
  • Cold hands and feet.
  • Cold all over.
  • Infertility.
  • Sex drive reduced or lacking.
  • Chronic headaches at level of eyes.
  • Mental and/or emotional stress.
  • Abnormal thirst.
  • Excessive urination.

Thymus Health:

  • Very susceptible to infections.
  • Chronic swollen glands in neck/groin/armpit.
  • Frequent flu like symptoms.
  • Irregular heartbeat.
  • Soreness in neck.
  •  Infections last longer than seven days.
  • Over the age of 50.

Pineal Health:

  • Lack of co-ordination in the dark.
  • Symptoms worse in the evening.
  • Irregular sleep habits.
  • Symptoms worse in autumn and/or winter.

Prostate Health:

  • Increased urinary frequency.
  • Need to urinate during the night.
  • Reduced urine flow with increased strain.
  • Difficulty in urination or stopping urine flow.
  • Pain or burning during urination.
  • Discharge from penis after bowel movements.
  • Blood or pus in urine.
  • Back pain or leg pain.
  • Fever/chills.
  • Impotence(difficulty in maintaining an erection).
  • Lost or diminished sex drive.
  • Prostate trouble.
  • PSA test.

Reproductive Health Males:

  • Inability to achieve or maintain an erection.
  • Premature ejaculation.
  • Inability to ejaculate.
  • Low or diminished sex drive.
  • Currently taking medication (antihypertensives, tranquillizers or others).
  • Inability to impregnate a woman.
  • Low sperm count.

Genital Health Males:

  • Unusual discharge from penis.
  • Itchy genitals
  • Swelling or pain in genital area.
  • Recent changes in urination (frequency etc.).
  • Burning in the genital area.
  • Bumps or blisters on the genitals.
  • Visible warts on genitals
  • Diagnosed with sexually transmitted disease (herpes, gonorrhoea, warts,etc.)

Dysmenorrhoea:

  • Do you have any of these symptoms during menstruation:
  • Menstrual cramps. PMS
  • Lower abdominal pain.
  • Backache.
  • Pinching/pain sensations in inner thighs.
  • Intense cramps right before period.
  • Abdominal bloating.
  • Sugar craving.
  • Light or heavy blood flow.
  • Anxious about getting your period.
  • Stay in bed the first few days of period.
  • Pain during period is getting worse.

Amenorrhoea:

  • Lack of menstruation.
  • Irregular periods.
  • Vaginal itching or abnormal discharge.
  • Low sex drive.
  • Regularly do strenuous exercise.
  • Fifteen years or older and haven’t had a period.
  • Diagnosed or believe you have anorexia.
  • Unable to get pregnant.
  • 2.25-4.5 kilograms under your ideal weight.
  • Have you had any miscarriages.
  • Have you had any abortions.

PMS:

  • Depressed.
  • Altered sex drive.
  • Breast pain.
  • Backache.
  • Abdominal bloating.
  • Swelling in hands and feet.
  • Anxiety and/or suicidal feelings.
  • Easily irritated and/or mood swings.
  • Cramps.
  • Weight gain each month.
  • Crying for no apparent reason.
  • Sugar craving.
  • Headaches.
  • Lumps in the breasts.
  • PMT-A: anxiety, irritability and nervous tension.
  • PMT-C: increased premenstrual appetite, craving for sweets(mainly chocolate), refined sugar, resulting in fainting spells, fatigue, palpitations and headache.
  • PMT-D: depression, withdrawal, lethargic, suicidal tendencies, confusion, incoherence, difficulty verbalizing.
  • PMT-H: premenstrual sensation of weight gain, abdominal bloating, tenderness, breast congestion, oedema of face and extremities.

Fibrocystic Problems:

  • Small lumps in breast.
  • Breast pain and tenderness.
  • Breast swelling/tender to touch.
  • Painful ovaries.
  • Lower abdominal pain.
  • History of breast cancer in your family.
  • Never been pregnant.
  • Recent Pap smear test positive.
  • Ovarian or uterine cysts.
  • Endometriosis.
  • Mother used D.E.S.(hormones) while pregnant with you.
  • Sudden onset of pain on one side of abdomen halfway between monthly cycles.

Menopause:

  • Hot flushes.
  • Weight gain.
  • Memory loss.
  • Irritability/mood swings.
  • Depression.
  • Vaginal dryness and pain.
  • Anxiety (sometimes followed by chills).
  • Low sex drive/low arousal time.
  •  Heart palpitations.
  • Water retention.
  • Night sweats and/or sweat throughout the day.
  • Above symptoms and over age 45.
  • Have you had a hysterectomy?
  • Diagnosed with osteoporosis.

Muscle Health:

  • Experience muscle cramps.
  • Frequent muscle spasms.
  • Low back pain.
  • Leg muscles cramp at night.
  • Tight muscles.
  • Muscular discomfort or pain.
  • Muscle stiffness all over.
  • Muscle stiffness after a good night’s sleep.

Joint Health:

  • Mild early morning stiffness.
  • Loss or restriction of joint mobility.
  • Pain that is worse after using the joint.
  • Stiffness after periods of rest.
  • Creaking/cracking of joints.
  • Tenderness and swelling in certain areas.
  • Diagnosed with osteoarthritis.
  • Chronic fatigue and weakness.
  • Low grade fever.
  • Joint stiffness and joint pain.
  • Painful, swollen joints.
  • Diagnosed with rheumatoid arthritis.
  • Severe pain in first joint of big toe.
  • Constipation /indigestion.
  • Headaches.
  • Heart or kidney problems.
  • Diagnosed with gout.

Bone Health:

  • Have had spontaneous bone fractures.
  • Painful bones.
  • Eat lots of red meat-non pasture fed.
  • Are you postmenopausal.
  • Take anti-inflammatory medication often.
  • Smoker.
  • Drink alcohol excessively.
  • Taken synthetic thyroid medication for long period of time.
  • Have calcium deposits in joints.
  • Drink large amounts of cooldrinks/sodas and/or coffee.
  • Family history of osteoporosis.
  • Experienced early menopause(before 45 years of age).
  • Have a current bone fracture.

Connective Tissue:

  • Loss of range of joint motion.
  • Persistent back pain.
  • Localized joint pain or tenderness.
  • Swollen joints.
  • Prone to injury.
  • Double-jointed (over flexible joints)
  • Do you have tendonitis.
  • Do you have bursitis
  • Do you have a herniated disc.
  • Are you recovering from a current injury.

Neurological Health:

  • Experience tremors in hands and/or feet.
  • Often nervous or ‘on edge’.
  • Slurred speech.
  • Easily lose your balance.
  • Tire easily.
  • Easily irritated.
  • Frequent dizziness/lightheadedness.
  • Lack of co-ordination.
  • Memory problems.
  • Depression.
  • Spaciness.
  • Ringing in the ears.
  • Extremities numb easily.
  • Head and/or limbs feel heavy.
  • Blurred or double vision.
  • Convulsions.
  • Loss of muscle tone or muscle strength.
  • Diagnosed with shingles.
  • Lose temper easily, emotionally unsettled.
  • Hyperactive behavior.

Basic Immune Function:

  • Easily susceptible to infections.
  • Frequent cold and flu.
  • Problems recovering from colds and flu.
  • Chronic swollen lymph glands.
  • Frequent sore throat.
  • Cuts or bruises heal slowly.
  • Hair grows slowly.
  • Frequent ear infections.
  • Cold sores or fever blisters.
  • Chronic low-grade fever.
  • Gums and/or nose bleeds.
  • Experience frequent runny nose.
  • Muscle aches and joint pain.
  • Frequently tired or fatigued, unrelieved by sleep.

Allergies-food or environment:

  • Known chemical sensitivities.
  • Known environmental and/or food allergies.
  • Irritability/mood swings.
  • Frequent headaches and/or migraines.
  • Abnormal fatigue not helped by rest.
  • Postnasal drip.
  • Frequent sneezing attacks and/or hay fever.
  • Weight fluctuations of 1.8-2.2 kilograms in one day accompanied by puffiness in face/ankles/fingers.
  • Chronic muscle aches and pains.
  • Suffer from asthma/breathing difficulties.
  • Eczema, hives or skin rashes.
  • Suffer from depression or bouts of crying.
  • Itchy eyes or nose.
  • Chronic runny nose.
  • Chronic stuffy nose.
  • Dark circles under eyes.
  • Frequent urination or bedwetting.
  • Swelling in joints.
  • Mouth or throat itches.
  • Chronic lymph gland swelling, especially in the throat area/under chin.
  • Acne.
  • Sweat for no apparent reason/hot flushes.
  • Suffer from irritable bowel, spastic colon or colitis.
  • Certain foods cause you to have a reaction ( jitters,depression,ill feelings etc.)
  • Strong cravings for certain foods, especially the common allergins like bread, grains, sugar and dairy.
  • Pulse races after eating certain foods or for no apparent reason.
  • Mucous in stool.
  • Minor chronic complaints that tend to recur.
  • Feel best when you do not eat.
  • Hyperactive.
  • Abdominal pain after eating.
  • Alternating diarrhoea and constipation.

Lymphatic system:

  • Have you ever had lymph nodes removed.
  • Have you had a goiter.
  • Gray hair.
  • Fibromyalgia or Scleroderma.
  • Sinus problems.
  • Frequent sore throat.
  • Swollen lymph nodes/glands anywhere on the body.
  • Tumors– Fattey/Benign/Malignant.
  • Low blood platelet count.
  • Is your immune system weak or sluggish.
  • Appendicitis or appendectomy. When.
  • Do you get boils pimples or cysts.
  • Ever had abscesses
  • How much exercise do you get.
  • Have you ever been diagnosed with toxemia or cellulitis.
  • Blurred vision.
  • Do you have mucous in your eyes when you wake up.
  • Do you snore.
  • Suffer from sleep apnea.
  • Have you had your tonsils out. At what age.

Environmental Toxins:

  • Vaccination history.
  • Shots when travelling to other countries.
  • Flu shots.
  • Mercury Amalgams.
  • Exposure to mining, nuclear waste or by-products, coal or gold mining, asbestos, chemicals, heavy metals.

Ever had radiation, mamograms or chemotherapy.

Methylation Questions:

  • Have you had your blood Histamine levels tested?This establishes whether you are an undermethylator or overmethylator or normal at this point.
  • Do you eat animal protein-meat, eggs, dairy, poultry etc daily?
  • Are the servings of protein the size of the palm of your hand?
  • Do you eat foods containing margarine(hydrogenated fats made from seed oils), or cooked processed foods more than twice a week?
  • Do you eat more than a cup of dark leafy greens daily?
  • Do you have more than 3 alcoholic drinks per week?
  • Do you eat 4-5 cups of fruit and or vegetables daily? How much fruit? How much vegetables?
  • Do you get moody, angry or depressed often?
  • Have you a history of heart attacks, other heart problems or stroke?
  • Do you have a cancer history? (especially colon,cervix, breast)
  • Do you have a history of abnormal PAP tests? (cervical dysplasia)
  • Do you have a history of birth defects in offspring? (neural tube defects or Down syndrome)
  • Have you had a miscarriage?
  • Do you have a history of dementia?
  • Do you have a loss of balance or sensation in your feet?
  • Do you have a history of multiple sclerosis or other diseases which include nerve damage?
  • Do you have a history of carpal tunnel syndrome?
  • Do you take B complex of multivitamins?
  • Are you over 65 years old?

Inflammation Questions:

  • Seasonal or environmental allergies.
  • Food allergies or sensitivities. Do not feel well after eating-feel sluggish, headaches, confusion etc.
  • Work in an environment with poor lighting, chemicals, and/or toxic bosses and coworkers.
  • Get frequent colds and infections,.
  • History of chronic infections such as hepatitis, skin infections,canker sores and/or cold sores.
  • Suffer from sinus and allergies.
  • Family history of bronchitis or asthma.
  • Have dermatitis(eczema, acne, rashes,itches).
  • Suffer from arthritis, osteoarthritis/degenerative wear and tear.
  • Family history of autoimmune disease (rheumatoid arthritis, lupus, hypothyroidism etc)
  • Family history of colitis or inflammatory bowel disease.
  • Family history of irritable bowel syndrome (spastic colon)
  • Neuritis ( problems like mood and behavior problems).
  • Had a heart attack or a family history of heart disease.
  • Overweight. (BMI greater than 25. or a family history of diabetes)
  • Family history of Parkinson’s or Alzheimer’s.
  • Do you have a stressful life?
  • Drink more than 3 glasses of alcohol a week.
  • Do exercise more than 30 minutes 3 times a week.

Toxins Quiz:

  • Hard difficult to pass bowel movements every day or every other day.
  • Constipated and only go every other day or less often.
  • Urinate small amounts of dark, strong-smelling urine only a few times a day.
  • Almost never break up in a real sweat.
  • Experience: fatigue, muscle aches, headaches, concentration and memory problems
  • Have or have a family history of  fibromyalgia or chronic fatigue syndrome.
  • Drink unfiltered tap or well water from plastic bottles.
  • Dry clean your clothes.
  • Work or live in a building with poor ventilation or windows that do not open.
  • Live in a large urban or industrial area.
  • Use household or lawn chemicals or get my home or apartment treated for bugs by an exterminator.
  • Have more than 1-2 mercury amalgams(fillings) in my teeth.
  • Eat large fish-shark or tuna or swordfish more than once a week.
  • I am bothered by one or more of the following: petrol or diesel fumes; perfumes; new car smell; fabric stores; dry cleaned clothes; hair spray; other strong odors; soaps; detergents; tobacco smoke; chlorinated water.
  • Do you have a negative reaction when you consume foods containing MSG, sulfites(found in wine, salad bars, dried fruit), sodium benzoate(preservative), red wine, cheese, bananas, chocolate, garlic, onions, or even a small amount of alcohol.
  • Does drinking caffeine make you feel wired, experience an increase in joint and muscle aches and/or have hypoglycemic symptoms(anxiety, palpitations, sweating, dizziness).
  • Do you regularly consume any of the following substances or medications: Acetaminophen (Tylenol), Acid-blocking drugs (Tagamet, Zantac,), Hormone-modulating medications in pills, patches, or creams( the pill, oestrogen, progesterone, prostate medication), Ibuprofen or naproxen, Medications for recurrent headaches, allergy symptoms, nausea, diarrhoea or indigestion.
  • Have you had jaundice(skin and whites of eyes turning yellow) for any reason or have you been told that you have Gilbert’s syndrome( an elevation of bilirubin)
  • You have a history of breast cancer, smoking induced cancer, other types of cancer, prostate problems, food allergies, sensitivities or intolerances.
  • A family history of Parkinson’s, Alzheimer’s, ALS (amylotrophic lateral sclerosis) or other motor neuron diseases, or multiple sclerosis.

Oxidative Stress Questions:

  • Fatigued on a regular basis.
  • Get less than 8 hours sleep a night.
  • Don’t exercise regularly or exercise more than 15 hours a week.
  • Sensitive to perfume, smoke, or other chemicals or fumes.
  • Regularly experience deep muscle or joint pain.
  • Am exposed to a significant level of environmental toxins (pollutants, chemicals etc) at home or work.
  • Smoke cigarettes, cigars (or anything)
  • Exposed to second hand smoke.
  • Drink more than 3 alcoholic drinks a week.
  • Don’t use sunblock.
  • Take prescription, over the counter and/or recreational drugs.
  • Rate your life as stressful.
  • Eat fried foods, margarine, or a lot of animal fat (meat ,cheese, etc).
  • Eat white flour and sugar more than twice a week
  • Eat fewer than 5 servings of colored vegetables a day.
  • Chronic colds and infections (cold sores,canker sores, etc)
  • You do not take antioxidant supplements daily.
  • Overweight (BMI more than 25)
  • Family history of diabetes or heart disease.
  • Have arthritis or allergies.
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Published by

michaelrault

Michael Rault is a highly qualified and passionate Health Coach, with many years experience practicing as a Naturopathic and Homeopathic doctor.

One thought on “Health Questionaires. A Self Assessment.”

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