HEALTH EVALUATION FORM

  • DUPLECHAIN INNOVATION WELLNESS CLINIC (Health Screening Form)

  • (STEP 1) Before you begin, please read each section carefully before summitting your response.

  • Part 1. New Client Information

  • Your Sex*

  • Part 2. Referral

  • Format: (000) 000-0000.

  • Part 3. Medical Information

  •
  • PLEASE CHECK ALL THAT APPLY.
  • Do you feel cold often or have a hard time getting warm?
  • Are you cold, but burning inside?
  • Is it easy to put on weight and hard to lose it?
  • Do you have an irregular heartbeat?
  • Do you become irritable easily?
  • Do you have, or have you ever had, a goiter?
  • Have you been diagnosed with Hashimoto or Reidel Disease?

  • Parathyroid (Glandular System)

  • Do you have varicose or spider veins?
  • Do you have or had, hemorrhoids or prolapsed organs?
  • Do you experience cramping in your muscles?
  • Is your bladder strong or weak?
  • Do you have or had a hernia?
  • Do you have or had an aneurysm?
  • Do you have osteoporosis and/ or score low on your bone density tests?
  • Do you have scoliosis?
  • Do you suffer from symptoms of depression?
  • Do you suffer from any other mental illness?
  • Did your test come back showing low calcium levels?
  • Do you have spine deterioration, herniated discs, or bone spurs?
  • Do your legs get tried or cramp after you walk?
  • Do you bruise easily?

  • Pancreas

  • Do you get gas after you eat?
  • Do you feel your foods just sitting in your stomach?
  • Do you have acid reflux? (heartburn)
  • Do you see any undigested foods in your stools?
  • Are you thin and have a hard time putting on weight?
  • Do your foods pass right through your (diarrhea)?
  • Do you have moles on your body? (Adrenal & Pancreatic weakness)

  • Adrenal Glands (Glandular System)

  • Do You have M.S., Parkinson's, or Palsy?
  • Do you have anxiety attacks or feel overly anxious?
  • Do you feel excessive shyness or inferior to others?
  • Do you have tremors, nervous legs, ect?
  • Do you have hypoglycemia (low blood sugar)?
  • Do you have diabetes (high blood sugar)?
  • Do you have high blood pressure?
  • Do you have high cholesterol?
  • Do you have tinnitus (ringing in the ears)?
  • Do you have S.OB. (shortness of breath) or is it hard to take a deep breath?
  • Do you have a sleeping problem (Pineal)? (Sleep Apnea or Insomnia)
  • Do you have Chronic Fatigue Syndrome?
  • Do you have Addison's Disease or Congenital Adrenal Hyperplasia?
  • Do you have low seroid or cortisol levels?
  • Have you been diagonsed with Autism?
  • Have you been diagnosed with ADD (Attention Deficit Disorder) or ADHD (Attention deficit Hyperactivity Disorder)?

  • Females Only

  • Are your menstruation cycles irregular (Pituitary)
  • Do you have excessive bleeding during menstruation?
  • Do you have heavy bleeding during menstruation?
  • Do you have or have you had ovarian cysts? When?
  • Do you have fibroids, and if so how long?
  • Do you have or had Endometriosis or A-typical cells? Which one?
  • Do you have or have you had fibrocystic breasts? When?
  • Do you get sore breasts, especially during menstruation?
  • Do You have a low or excessive sex drive?
  • Have you had a hysterectomy? Date?
  • Did they take any other organs out at the same time? (i.e: gallbladder) If yes, what other organs?
  • Have you had a miscarriage? When?
  • Have you had a D & C? If yes, What date:
  • Have you had difficulty conceiving children in the past or recently?
  • Have you been on birth control pills or any other method?
  • Are you currently pregnant?

  • Men Only

  • Do you experience any of the below problems?
  • Do you have prostatitis (frequent urination esp. at night)?
  • Do you have prostate cancer?
  • Do you have testicular hypertrophy (enlargement)?
  • Do you have a low or excessive sex drive?
  • Do you have premature ejaculation? Other

  • Gastro-Intestinal Tract

  • Do you have gastritis or enteritis?
  • Is your tongue coated (white, yellow, green, or brown), especially in the morning?
  • Do you have gastroparesis?
  • Do you have a Hiatus Hernia?
  • Do you have Colitis?
  • Do you have Diverticulitis?
  • Do you get or have Diarrhea?
  • Do you get or have Constipation?
  • Have you ever had stomach or intestinal ulcers?
  • Do you or have you had any type of gastro-intestinal cancers? (Stomach, colon, rectal, ect.)
  • Do you have Crohn's Dieses?
  • Do you have "gas" problems?

  • Heart and Circulation

  • Do you get chest pains or angina?
  • Have you ever had a heart attack (Myocardial Infarction)?
  • Have ever had open - heart surgery?
  • Do you have heart arrhythmia's? (Types Wolff-Parkinson-White Syndrome; Ventricular Arrhythmias; Premature Beats; Ventricular Premature Complexes; Atrial Premature Complexes and Sick Sinus Syndrome.
  • Do you ever feel pressure on your chest?
  • Do you get "Prickly" pains anywhere, especially in the heart area?
  • Do you have a Pacemaker or Stents?

  • Skin

  • Do you get or have skin rashes?
  • Do you get skin blemishes?
  • Do you have Eczema or Dermatitis?
  • Do you have Psoriasis?
  • Do you itch anywhere?
  • Is your skin dry?
  • Is your skin dry and scaly?
  • Is your skin excessively oily?
  • Do you get or have dandruff?
  • Do you have any other skin problems?
  • Do you have any tattoos: If so, where and how much of your body is covered?

  • Lymphatic System

  • Have you ever had Lymp Nodes removed?
  • Do you have any gray hair?
  • Do you have a hard time remembering things?
  • Do you ever get colds or flu-like symptoms?
  • Do you have fibromyalgia or scleroderma?
  • Do you have sinus congestion and problems?
  • Do you have or get sore throats?
  • Do you have swollen lymph nodes?
  • Do you have or have you had tumors?
  • Do you have a low platelet count (blood)?
  • Have you had appendiitis or an appendectomy?
  • Do you get boils, pimples, cysts, etc?
  • Do you get regular exercise?
  • Have you ever had abscesses?
  • Have you ever had txemia?
  • Do you have, or have you had, cellulitis? (not cellulite- this is different)?
  • Have you ever had gout?
  • Do you get blurred vision?
  • Do you have mucus in your eyes when you wake up in the morning?
  • Do you snore?
  • Do you have sleep apnea?
  • Have you had your tonsils out?

  • Kidneys and Bladder

  • Have you ever had a urinary tract infractions (UTI's)?
  • Have you ever had "burning" upon urination?
  • Do you have problems holding your bladder? (Parathyroid)?
  • Have you ever had kidney stones?
  • Do you have bags under your eyes (esp. in the morning)?
  • Is your urine flow restricted?
  • Do you get cramping or pain on either side of your mid-to-lower back?
  • Do you or did you ever have nephritis?
  • Do you have lower back weakness?
  • Do you have or have you had sciatic?
  • Do you or did you ever have cystitis?

  • Liver/ Gallbladder/ Blood

  • Do you have you been diagnosed with you ever had hepatitis? If So"

  • Lungs

  • Do you have Covid19 or have you had Covid19?
  • Do your have bronchitis or have you had bronchitis?
  • Do have emphysema or had emphysema?
  • Do you have or have you had Asthma?
  • Do you have or have you had C.O.P.D?
  • Are you on inhalers or nebulizers?
  • Do you have pain when you breathe?
  • Do you have pain when you take a deep breath? (adrenals)?
  • Is it difficult to take a deep breath?
  • Did you ever or do you have lung cancer?
  • Do you or have you had collapsed lung??
  • Are you a smoker?
  • Do you have pneumonia?
  • Have you ever worked around toxic chemicals, in coal mines or around asbestos?
  • Do you cough a lot?
  • Do you remove any mucus when you cough?*

  • Environmental and Other Chemicals

  • Have you been vaccinated?
  • Have you had the Covid19 vaccine?
  • Have you had shots for traveling to foreign countries?
  • Have you had Flu Shot?
  • Do you have mercury amalgams?
  • Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?
  • Have you had radiation or chemotherapy?
  • Have you ever used any form of recreations drugs? (This information is confidential and used to help obtain optional health only!)
  • Do you still use them?

  • Prescription Medications

    (List any prescription medications that you are presently taking.)

  • Natural Supplements

    (List any natural herbs and/or supplements that you're presently taking.)

  • Allergies

  • Past Surgeries

    Organ Transplant; Heart Surgery, Fibroids Removed, Ect. (Also Cosmetic Surgeries,  Liposuction BBL, Gastric Bypass, Breast Augmentation, Bariatric Surgery Ect.)

  • What Are Your Major Health Complaints or Concerns?

  • Conclusion

  • Once completed press the "SUBMIT BUTTON" are we will not receive your health evaluation form. Our response time to communicate back to you is 48-72 hours during regular business hours. Or We Will Not Receive Your Health Evaluation Form. Our Response Time To Health Forms Is 48-72 Hours

    • All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
    • I am submitting this form so Duplechain Holistic Health & Fitness can contact me with a respond to my health concerns, and match me up with the best products. Also, to keep me informed about their products, services, and when items go on sale. I understand that I do have to submit this form to initiate contact with us.  
    • We will respond to your health form within 48-72 days. if you want to do a compleimentry phone consulatation cick the link below. 

    CLICK THIS LINK TO SCHEDULE COMPLIMENTARY CONSULTATION

  • I AGREE to the above terms and conditions.
  • Should be Empty: