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
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
Format: (000) 000-0000.
Email
example@example.com
Part 3. Medical Information
Have you used any of our products at Duplechain Innovation Wellness Clinic?
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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1 is Poor, 10 is Athlete
How would you rate your current physical fitness?

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How would you rate your current physical nutrition?

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How well do you sleep?

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How many hours do you sleep?
How well do you handle stress?

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Do you feel cold often or have a hard time getting warm?
Are you cold, but burning inside?
Do you become irritable easily?
Do you have, or have you ever had, a goiter?
Have you been diagnosed with Hashimoto or Reidel Disease?
INTEGUMENTARY SCREENING QUESTIONS
Do you currently have any rashes, hives, sores, wounds, or skin lesions that are new, worsening, or not healing?
Have you noticed any changes in a mole or new skin growth (such as changes in size, shape, color, or bleeding)?
Do you have persistent itching, redness, dryness, unusual skin discoloration, or frequent bruising?
Have you experienced excessive hair loss or significant changes in your hair or nails (such as brittle, thickened, or discolored nails)?
Have you noticed any breast lumps, nipple discharge, breast skin changes, or persistent breast pain?
Additional Information
Comment additional information or N/A
Skeletal/Musculoskeletal Screening Questions
Do you have persistent back pain or neck pain?
Do you have joint pain, muscles stiffness, swelling, or decreased flexibility?
Have you experienced any recent fractures, broken bones, or bone injuries?
Have you noticed muscle weakness or difficulty performing your usual daily activities?
Have you had any recent muscle injuries, strains, or tears?
Have you noticed any bone deformities, changes in posture, loss of height, or curvature of the spine?
Do you have difficulty walking, climbing stairs, lifting objects, or maintaining your balance due to muscle problems?
Have you been diagnosed with osteoporosis, osteopenia, arthritis, or any other bone or joint disorder?
Additional Information
Comment additional information or N/A
Nervous Screening Questions
Do you experience frequent headaches, dizziness, or episodes of fainting?
Have you had numbness, tingling, weakness, or loss of sensation in any part of your body?
Have you experienced seizures, tremors, or involuntary movements?
Have you noticed problems with your memory, concentration, balance, coordination, or walking?
Have you experienced changes in your vision, speech, swallowing, or episodes of confusion?
Additional Information
Comment additional information or N/A
Circulatory (Cardiovascular) Screening Questions
Do you experience chest pain, chest pressure, or discomfort during activity or while at rest?
Do you become short of breath during normal daily activities or when lying flat?
Do you have edema, swelling in your feet, ankles, legs, or hands that occurs regularly?
Do you frequently experience dizziness, fainting, heart palpitations (racing, pounding, or skipping heartbeat), or poor circulation (cold, numb, or discolored hands or feet)?
Have you ever been diagnosed with high blood pressure, heart disease, irregular heartbeat/skipped beats, rapid/pounding beats, palpitations, heart failure, stroke, or high cholesterol?
Additional Information
Comment additional information or N/A
Respiratory Screening Questions
Do you currently have chest congestion, persistent mucus, or frequent coughing?
Have you ever been diagnosed with asthma, chronic bronchitis, COPD, or another lung condition?
Do you experience shortness of breath during normal daily activities, exercise, or while at rest?
Have you had episodes of difficulty breathing, wheezing, or chest tightness?
Have you had recurrent bronchitis, pneumonia, or other respiratory infections within the past 12 months
Additional respiratory concerns or N/A:
Additional respiratory concerns:
Current respiratory medications or inhalers or N/A:
Current respiratory medications or inhalers:
Smoking or vaping history or N/A:
Smoking or vaping history:
Digestive Screening Questions
PLEASE CHECK ALL THAT APPLY.
If you checked any of the above, please explain
If you checked any of the above, please explain or N/A
Endocrine Screening Questions
PLEASE CHECK ALL THAT APPLY.
If you checked any of the above, please explain
If you checked any of the above, please explain or N/A
Urinary Screening Questions
Do you experience pain, burning, or discomfort when urinating?
Have you noticed blood in your urine or a change in urine color?
Do you urinate more or less frequently than usual, especially at night?
Have you had recurrent urinary tract infections, kidney infections, or kidney stones?
Do you experience swelling in your feet, ankles, hands, or around your eyes?
Immune (Lymphatic) Screening Questions
Do you frequently experience infections that are difficult to recover from?
DHave you noticed swollen lymph nodes in your neck, armpits, or groin?
Do you experience unexplained fevers, chills, or night sweats?
Have you experienced unexplained weight loss, persistent fatigue, or weakness?
Have you experienced unexplained weight loss, persistent fatigue, or weakness?
Reproductive Screening Questions
Have you experienced any pain, swelling, lumps, or discomfort in your reproductive or pelvic area?
Have you noticed any unusual discharge, sores, rashes, itching, or changes involving your genital area?
Do you have any concerns about your sexual health, sexual function, libido, or fertility?
Have you ever been diagnosed with a sexually transmitted infection (STI), reproductive disorder, or reproductive cancer?
Have you experienced any recent changes in your reproductive health, such as abnormal bleeding, menstrual changes, pelvic pain, prostate symptoms, erectile dysfunction, or testicular discomfort?
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?
When
What year did you have ovarian cysts?
Do you have fibroids, and if so how long?
How long have you had fibroids and sizes of fibroids?
Do you have or had Endometriosis or A-typical cells? Which one?
Which one?
Do you have or have you had fibrocystic breasts? When?
When?
Do you get sore breasts, especially during menstruation?
Do You have a low or excessive sex drive?
Have you had a hysterectomy? Date?
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?
If Yes, what other organs?
Have you had a miscarriage? When?
When?
Have you had a D & C? If yes, What date:
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?
How long?
Are you currently pregnant?
Men Only
Do you experience any of the below problems?
Do you have prostatitis (frequent urination esp. at night)?
If yes, how often do you urinate?
Do you have prostate cancer?
What are your PSA counts ? Date:
Do you have testicular hypertrophy (enlargement)?
Do you have a low or excessive sex drive?
Do you have premature ejaculation? Other
Other:
Gastro-Intestinal Tract
Do you have gastritis or enteritis?
Is your tongue coated (white, yellow, green, or brown), especially in the morning?
Which color is your tongue?
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.)
Explain:
Do you have Crohn's Dieses?
Do you have "gas" problems?
Other GI problems:
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?
Where?
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?
If so, what type?
Do you have any tattoos: If so, where and how much of your body is covered?
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?
Where and how many?
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?
If so, where?:
Do you have a low platelet count (blood)?
Have you had appendiitis or an appendectomy?
If Yes, When?
Do you get boils, pimples, cysts, etc?
Do you get regular exercise?
How many times per weeks? What type of 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?
What age?
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
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"
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?
Date(s) of 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?
If yes, how often? What medications? What is your oxygen saturation level?
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?
When?
Do you or have you had collapsed lung??
When?
Are you a smoker?
How often? Pack per day? or Cigarettes per day?
Do you have pneumonia?
When and how often 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?
What color is the mucus? (Clear, yellow, green, brown, or black?)
Environmental and Other Chemicals
Have you been vaccinated?
Have you had the Covid19 vaccine?
Which vaccine Pfizer, Johnson & Johnson, & Moderna?
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?
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!)
Do you still use them?
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.
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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

INTEGUMENTARY SCREENING QUESTIONS

Skeletal/Musculoskeletal Screening Questions

Nervous Screening Questions

Circulatory (Cardiovascular) Screening Questions

Respiratory Screening Questions

Digestive Screening Questions

Endocrine Screening Questions

Urinary Screening Questions

Immune (Lymphatic) Screening Questions

Reproductive Screening Questions

Females Only

Men Only

Gastro-Intestinal Tract

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