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
Full Name*

First NameLast Name
Your Sex*

MaleFemale
Age *
Number of Children*
Your Height*
Example: 6'1
Your Weight *
Example: 185
E-mail*
example@example.com
Best Contact Number
Part 2. Referral
Did one of our clients refer you? If so, list their name, phone, and email.

First NameLast Name
Phone Number
Email
example@example.com
Part 3. Medical Information
Have you used any of our products at Duplechain Holistic Health & Fitness?
Do you currently have a primary care physician?
Primary Care Physican Name
How many bowel moments do you have per day?
How often do your bowels move per week?
What is your energy level?

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10

1 is Poor, 10 is Athlete
How would you rate your current physical fitness?

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1 is Poor, 10 is Athlete
How would you rate your current physical nutrition?

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1 is Poor, 10 is Athlete
How well do you sleep?

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1 is Poor, 10 is Athlete
How many hours do you sleep?
How well do you handle stress?

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1 is Poor, 10 is Athlete
PLEASE CHECK ALL THAT APPLY.

AIDSAcneAir Hunger, Labor Breathing or SighingAllergiesAnemiaArrhythmia, Palpitations (Irregular Heartbeats)AsthmaAttention Deficit Disorder (ADD)Bleeding GumsBloating, Belching or BurpingBlood Sugar Imbalances (Hypoglycemia or Diabeties)Brain FogBrittle, Weak or Ridged NailsCalf TendernessCancerCataractsChocolate CravingsChronic PainClogged or Calcified ArteriesCold Hands or FeetCracks in Corners of the Mouth (Cheilosis)Cysts (Fibrocystic Breast and Ovarian Cysts)Dizzy When Standing Up Too FastEdema (Fluid Retention)Excessive Brain Chatter (at night)Excessive Worrying and AnxietyFatigueFatty LiverFrequent Urination (Polyuria)GallstonesGets Sick EasilyGraves' DiseaseHair LossHair ThinningHashimoto's Disease (Autoimmune)Headaches/MigrainesHearing LossHigh Pulse RateHIVHot FlashesHyperthyroidHypothyroidismIndigestionInfertilityItchingLeaky GutLegs Get Heavy After Climbing or Doing Inclined ExerciseLipoma (Fatty Cyst on Body)Loose Skin (Loss of Collagen)Loss of Hair in Patches (Alopecia)Loss of MemoryLoss of Outer EyebrowsLoss of Vitality (get up and go)Low Libido (woman)Low Testosterone (men)Low Tolerance to StressLow Vitamin D LevelsMale Pattern BaldnessMid-back Pain or TightnessMuscle Twitches (Tetany)Neck PainNeed for Afternoon NapNightmaresNot Satisfied After MealsOsteoporosis or OsteopeniaOut of Breath when Climbing StarisPainful IntercoursePCOP (Polycystic Ovarian Disorder)PMSPoor Night VisionProstate EnlargementPsoriasis (Dry Flaky Skin Patches)Right Shoulder PainRosacea (red Cheeks)Salt CravingsSensation of Sand or Irritation in EyesSmall Pimples (not red ) on SkinSpurs (Heel, joints, ect.)Stubborn WeightSugar CravingsTakes Too Long To Recover from ExerciseTingling, Burning, or Numbness in Fingers or ToesTrigger Finger(Dupuytren's Contracture)UlcerUrinary FrequencyVaginal DrynessVaricouse Veins or Spider VeinsWakes Up ExuaustedWakes up in the Middle of the Night
Do you feel cold often or have a hard time getting warm?

YesNo
Are you cold, but burning inside?

YesNo
Is it easy to put on weight and hard to lose it?

YesNo
Do you have an irregular heartbeat?

YesNo
Do you become irritable easily?

YesNo
Do you have, or have you ever had, a goiter?

YesNo
Have you been diagnosed with Hashimoto or Reidel Disease?

Hashimoto DiseaseReidel DiseaseNone
Parathyroid (Glandular System)
Do you have varicose or spider veins?

VaricoseSpider VeinsNone
Do you have or had, hemorrhoids or prolapsed organs?

HemorrhoidsProlapsed OrgansNone
Do you experience cramping in your muscles?

YesNo
Is your bladder strong or weak?

StrongWeak
Do you have or had a hernia?

YesNo
Do you have or had an aneurysm?

YesNo
Do you have osteoporosis and/ or score low on your bone density tests?

YesNo
Do you have scoliosis?

YesNo
Do you suffer from symptoms of depression?

YesNo
Do you suffer from any other mental illness?

YesNo
Did your test come back showing low calcium levels?

YesNo
Do you have spine deterioration, herniated discs, or bone spurs?

Spine DeteriorationHerniated DiscsBone SpursNone
Do your legs get tried or cramp after you walk?

YesNo
Do you bruise easily?

YesNo
Pancreas
Do you get gas after you eat?

YesNo
Do you feel your foods just sitting in your stomach?

YesNo
Do you have acid reflux? (heartburn)

YesNo
Do you see any undigested foods in your stools?

YesNo
Are you thin and have a hard time putting on weight?

YesNo
Do your foods pass right through your (diarrhea)?

YesNo
Do you have moles on your body? (Adrenal & Pancreatic weakness)

YesNo
Adrenal Glands (Glandular System)
Do You have M.S., Parkinson's, or Palsy?

M.S.Parkinson'sPalsyNone
Do you have anxiety attacks or feel overly anxious?

YesNo
Do you feel excessive shyness or inferior to others?

YesNo
Do you have tremors, nervous legs, ect?

YesNo
Do you have hypoglycemia (low blood sugar)?

YesNo
Do you have diabetes (high blood sugar)?

PrediabetesGestational DiabetesType INoneType II
Do you have high blood pressure?

YesNo
Do you have high cholesterol?

YesNo
Do you have tinnitus (ringing in the ears)?

YesNo
Do you have S.OB. (shortness of breath) or is it hard to take a deep breath?

YesNo
Do you have a sleeping problem (Pineal)? (Sleep Apnea or Insomnia)

YesNo
Do you have Chronic Fatigue Syndrome?

YesNo
Do you have Addison's Disease or Congenital Adrenal Hyperplasia?

Addison's DiseaseNoneCongenital Adrenal HyperplasiaPast Diagnoses
Do you have any "itis's (inflammatory conditions)? Example arthritis, bursitis, rheumatoid arthritis, colitis, enteritis, phlebitis, neuritis, ect.

NoOther
Do you have low seroid or cortisol levels?

YesNo
Have you been diagonsed with Autism?

YesNo
Have you been diagnosed with ADD (Attention Deficit Disorder) or ADHD (Attention deficit Hyperactivity Disorder)?

YesNo
Females Only
Are your menstruation cycles irregular (Pituitary)

YesNo
Do you have excessive bleeding during menstruation?

YesNo
Do you have heavy bleeding during menstruation?

YesNo
Do you have or have you had ovarian cysts? When?

YesNo
When
What year did you have ovarian cysts?
Do you have fibroids, and if so how long?

YesNo
How long have you had fibroids?
Do you have or had Endometriosis or A-typical cells? Which one?

YesNo
Which one?
Do you have or have you had fibrocystic breasts? When?

YesNo
When?
Do you get sore breasts, especially during menstruation?

YesNo
Do You have a low or excessive sex drive?

YesNo
Have you had a hysterectomy? Date?

YesNo
What Date? Was It Partial or Complete Hysterectomy?
Did they take any other organs out at the same time? (i.e: gallbladder) If yes, what other organs?

YesNo
If Yes, what other organs?
Have you had a miscarriage? When?

YesNo
When?
Have you had a D & C? If yes, What date:

YesNo
If yes, what date?
Have you had difficulty conceiving children in the past or recently?

PastRecentlyN/A
Have you been on birth control pills or any other method?

YesNo
How long?
Are you currently pregnant?

YesNo
Men Only
Do you experience any of the below problems?

Low Sex DriveErection ProblemsProblems with ErectionsMore Body FatDepressionMood ChangesMuscles ChangesBone LossShrinking TesticlesSleeping ProblemsTestosterone ProblemsCardiovascular DiseaseTrouble ConcentratingLow Sperm Count
Do you have prostatitis (frequent urination esp. at night)?

YesNo
If yes, how often do you urinate?
Do you have prostate cancer?

YesNo
What are your PSA counts ? Date:
Do you have testicular hypertrophy (enlargement)?

YesNo
Do you have a low or excessive sex drive?

YesNo
Do you have premature ejaculation? Other

YesNo
Other:
Gastro-Intestinal Tract
Do you have gastritis or enteritis?

YesNo
Is your tongue coated (white, yellow, green, or brown), especially in the morning?

YesNo
Which color is your tongue?
Do you have gastroparesis?

YesNo
Do you have a Hiatus Hernia?

YesNo
Do you have Colitis?

YesNo
Do you have Diverticulitis?

YesNo
Do you get or have Diarrhea?

YesNo
Do you get or have Constipation?

YesNo
Have you ever had stomach or intestinal ulcers?

YesNo
Do you or have you had any type of gastro-intestinal cancers? (Stomach, colon, rectal, ect.)

YesNo
Explain:
Do you have Crohn's Dieses?

YesNo
Do you have "gas" problems?

YesNo
Other GI problems:
Heart and Circulation
Do you get chest pains or angina?

YesNo
Have you ever had a heart attack (Myocardial Infarction)?

YesNo
Have ever had open - heart surgery?

YesNo
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.

YesNo
What Kind?
Do you ever feel pressure on your chest?

YesNo
Do you get "Prickly" pains anywhere, especially in the heart area?

YesNo
Where?
Do you have a Pacemaker or Stents?

PacemakerStentsN/A
Skin
Do you get or have skin rashes?

YesNo
Do you get skin blemishes?

YesNo
Do you have Eczema or Dermatitis?

YesNo
Do you have Psoriasis?

YesNo
Do you itch anywhere?

YesNo
Where?
Is your skin dry?

YesNo
Is your skin dry and scaly?

YesNo
Is your skin excessively oily?

YesNo
Do you get or have dandruff?

YesNo
Do you have any other skin problems?

YesNo
If so, what type?
Do you have any tattoos: If so, where and how much of your body is covered?

YesNo
What is the approximate date of teh most recent tattoo?
Lymphatic System
Do you have hair loss (thinning), going bald (hair loss), or bald?
Have you ever had Lymp Nodes removed?

YesNo
Where and how many?
Do you have any gray hair?

YesNo
Do you have a hard time remembering things?

YesNo
Do you ever get colds or flu-like symptoms?

YesNo
Do you have fibromyalgia or scleroderma?

FibromyalgiaSclerodermaN/A
Do you have sinus congestion and problems?

YesNo
Do you have or get sore throats?

YesNo
Do you have swollen lymph nodes?

YesNo
Do you have or have you had tumors?

FattyBenignMalignantN/A
If so, where?:
Do you have a low platelet count (blood)?

YesNo
Have you had appendiitis or an appendectomy?

YesNo
If Yes, When?
Do you get boils, pimples, cysts, etc?

YesNo
Do you get regular exercise?

YesNo
How many times per weeks? What type of exercise?
Have you ever had abscesses?

YesNo
Have you ever had txemia?

YesNo
Do you have, or have you had, cellulitis? (not cellulite- this is different)?

YesNo
Have you ever had gout?

YesNo
Do you get blurred vision?

YesNo
Do you have mucus in your eyes when you wake up in the morning?

YesNo
Do you snore?

YesNo
Do you have sleep apnea?

YesNo
Have you had your tonsils out?

YesNo
What age?
Kidneys and Bladder
Have you ever had a urinary tract infractions (UTI's)?

YesNo
Have you ever had "burning" upon urination?

YesNo
Do you have problems holding your bladder? (Parathyroid)?

YesNo
Have you ever had kidney stones?

YesNo
Do you have bags under your eyes (esp. in the morning)?

YesNo
Is your urine flow restricted?

YesNo
Do you get cramping or pain on either side of your mid-to-lower back?

YesNo
Do you or did you ever have nephritis?

YesNo
Do you have lower back weakness?

YesNo
Do you have or have you had sciatic?

YesNo
Do you or did you ever have cystitis?

YesNo
Liver/ Gallbladder/ Blood
Have you noticed yellowing of your skin or eyes, dark urine, or pale stools?
Short Answer
Have you noticed digestive changes such as frequent indigestion, heartburn, dark urine, changes in bowel color, unexplained weight changes, or increased bruising or bleeding
Short Answer
Have you experienced persistent itching without a rash, noticed changes in your skin such as unexplained rashes, redness of the palms, or the appearance of spider-like blood vessels
Short Answer
Do you often feel very tired, weak, or have unexplained weight changes?
Short Answer
Do you have nausea, loss of appetite, or pain/swelling in the upper right side of your abdomen?
Short Answer
Have you experienced easy bruising, bleeding, or persistent itching?
Short Answer
Do you take medications, supplements, or herbs that could affect the liver?
Short Answer
Have you noticed swelling in your legs or abdomen, or episodes of confusion or poor concentration?
Short Answer
Have you had unexplained fevers, night sweats, or frequent infections?
Short Answer
Have you recently developed changes in sleep, mood, or memory?
Short Answer
Have you experienced shaking hands (tremors) or difficulty sleeping?
Short Answer
Do you sometimes feel confused, have trouble concentrating, or notice changes in your memory?
Short Answer
How often do you drink alcohol, and how much?
Short Answer
Have you ever been diagnosed with hepatitis, fatty liver, or any liver disease?
Short Answer
Do you have you been diagnosed with you ever had hepatitis? If So"

Alcoholic HepatitisAutoimmune HepatitisHepatitis AHepatitis BHepatitis CHepatitis DHepatitis EFatty Liver
Have you been exposed to possible bloodborne infections (tattoos, shared needles, unprotected sex, blood transfusions)?
Short Answer
Lungs
Do you have Covid19 or have you had Covid19?

YesNo
Date(s) of Covid19?
Do your have bronchitis or have you had bronchitis?

YesNo
Do have emphysema or had emphysema?

YesNo
Do you have or have you had Asthma?

YesNo
Do you have or have you had C.O.P.D?

YesNo
Are you on inhalers or nebulizers?

YesNo
If yes, how often? What medications? What is your oxygen saturation level?
Do you have pain when you breathe?

YesNo
Do you have pain when you take a deep breath? (adrenals)?

YesNo
Is it difficult to take a deep breath?

YesNo
Did you ever or do you have lung cancer?

YesNo
When?
Do you or have you had collapsed lung??

YesNo
When?
Are you a smoker?

YesNo
How often? Pack per day? or Cigarettes per day?
Do you have pneumonia?

YesNo
When and how often do you have pneumonia?
Have you ever worked around toxic chemicals, in coal mines or around asbestos?

YesNo
Do you cough a lot?

YesNo
Do you remove any mucus when you cough?*

YesNo
What color is the mucus? (Clear, yellow, green, brown, or black?)
Environmental and Other Chemicals
Have you been vaccinated?

YesNo
Have you had the Covid19 vaccine?

YesNo
Which vaccine Pfizer, Johnson & Johnson, & Moderna?
Have you had shots for traveling to foreign countries?

YesNo
Have you had Flu Shot?

YesNo
Do you have mercury amalgams?

YesNo
Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?

YesNo
Have you had radiation or chemotherapy?

RadiationChemotherapyN/A
If so, how many treatments and year of treatments?
Have you ever used any form of recreations drugs? (This information is confidential and used to help obtain optional health only!)

YesNo
Do you still use them?

YesNo
If so which drugs?
Prescription Medications

(List any prescription medications that you are presently taking.)
LIST ALL PRESCRIPTION MEDICATIONS OR N/A*
Natural Supplements

(List any natural herbs and/or supplements that you're presently taking.)
LIST ALL NATURAL HERBS AND SUPPLEMENTS YOU'RE TAKING OR N/A*
Allergies
LIST ALL ALLERGIES*
Past Surgeries

Organ Transplant; Heart Surgery, Fibroids Removed, Ect. (Also Cosmetic Surgeries, Liposuction BBL, Gastric Bypass, Breast Augmentation, Bariatric Surgery Ect.)
LIST ANY SURGERIES (Minor & Major SURGERIES)
What Are Your Major Health Complaints or Concerns?
Please list any conditions or symptoms that were not covered in this questionnaire.
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.

YesNo
Should be Empty:

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

Part 2. Referral

Part 3. Medical Information

Parathyroid (Glandular System)

Pancreas

Adrenal Glands (Glandular System)

Females Only

Men Only

Gastro-Intestinal Tract

Heart and Circulation

Skin

Lymphatic System

Kidneys and Bladder

Liver/ Gallbladder/ Blood

Lungs

Environmental and Other Chemicals

Prescription Medications

Natural Supplements

Allergies

Past Surgeries

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