Health Code Questionnaire
*Note: Not all questions are compulsory - please answer as many as you feel comfortable with.
Name
*
First Name
Last Name
How old are you?
*
Sex
*
Male
Female
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
IMMUNE SYSTEM
1. Were you sick easily when you were a baby or child?
No
If Yes, please specify what were you experiencing (high fever, flu, runny nose, digestion issues, etc)
Have your parents treated symptoms (high fever, coughing, common cold, flu, etc.) with antibiotics or other medication (please specify which one you know or remember) when you were a baby or child?
2. Have you ever been diagnosed with an autoimmune disease? Please specify.
No
If Yes, please specify when, which disease, what symptoms do you experience
3. Have you ever had:
Asthma
Allergies
Acid reflux
No I didn't have
If Yes, please specify when were you diagnosed, what symptoms do you experience
4. Have you ever been diagnosed with a virus?
Yes, Please choose from below ones
No
If Yes, select Type of Virus:
Glandular Fever/Mono/Epstein-Barr Virus
Herpes
Coldsores
Chickenpox
Shingles
Ross River Fever
Mumps
Measles
Rubella
Influenza
HPV/Human Papilloma Virus
Hepatitis
Dengue Fever
Croup
Gastroenteritisor “StomachFlu”
Other
When did you get the virus?
5. When stressed, do you experience:
*
Cold sores
Hives
Shingles
Chronic fatigue
Other, please specify
6. I have never felt the same after.... (what have happened that after some event, occasion you do not feel the same after it)
*
HORMONE
1. Any sleep disturbances?
No
If Yes, please specify
If Yes, since when do you have sleep disturbances?
2. When you wake up in the morning, how do you feel?
Energised
Want to sleep longer
3. Do you get cravings for sugar or salt?
No
If Yes, please specify
4. Do you have difficulty losing and or gaining weight regardless of the diet/exercise regimen you follow?
No
If Yes, please specify for how long you have been trying, what methods (from nutrition, training, supplements, drugs) you were using to gain or lose weight?
THYROID
1. Do you get cold hands/feet?
Yes
No
2. Do you easily gain weight?
Yes
No
3. Do you experience constipation?
Yes
No
4. Do you have history of high cholesterol?
Yes
No
5. Do you need coffee to "survive the day"?
Yes
No
ESTROGEN (for Females)
1. Have you been diagnosed with:
PCOS
Fibroids
Endometriosis
No, I have never been diagnosed
Other, please specify
If yes when you were diagnosed?
2. Do you have a history of migraines?
Yes
No
3. Do you experience:
Hair loss
Low sex drive
Hot flashes
Nothing I feel great
Other, please specify
4. How was your first menstrual period (Menarche)?
Normal
Painful
Heavy bleeding
Lasted very long
Other, please specify
5. After the first menstrual period, were your second, third, fourth,... period were regular:
Yes
No
If NOT, please specify how were you feeling symptoms wise, after the first menstrual period, and how regular or irregular your periods were:
6. Have you experienced irregular menstrual cycles?
Yes
No
If Yes, when irregular menstrual cycle started?
7. Are you getting unwanted hair on:
Face
Chin
Body
No, I don't have unwanted hair issue
Other, please specify
8. Have you been using or currently using birth control pills ?
*
No
If Yes, please specify for how long
TESTOSTERONE (for Males)
1. Do you have difficulty gaining muscle weight when working out?
Yes
No
2. Do you experience low sex drive?
Yes
No
3. Are you easily gaining fat deposits?
Yes
No
4. Have you noticed an increase in body fat, particularly around the abdomen?
No
Yes
5. Do you often feel depressed, down, or irritable without a clear reason?
No
Yes
6. Have you noticed a decrease in your motivation or drive to accomplish goals?
No
Yes
7. Do you feel less mentally sharp or experience brain fog regularly?
No
Yes
BLOOD SUGAR
1. Have you ever been diagnosed with Diabetes?
No
If Yes, please specify when and what symptoms you were experiencing?
2. Do you frequently get thirsty?
Yes
No
3. Do you experience difficulties urinating?
Urinating too often
Difficult urinating
Itchiness during or after urinating
No I don't
If other, please specify
If Yes, when was the first time you start to experience issues with urination?
4. How do you feel after a meal?
Tired / Fatigues
Energized
5. Do you feel ‘stressed/irritated’ in the morning before breakfast?
Yes
No
6. Do you feel hungry at the evening before going to sleep?
No
If Yes, what do you usually eat
DIGESTION
1. Do you experience gas and/or bloating after eating?
No
If Yes, please specify, when it started, did you try something to help you with gas or bloating, and what makes your symptoms worse?
2. How do you feel after taking probiotics? Any problems?
3. Have you been diagnosed with
Stomach ulcers or gastritis
Helicobacter Pylori
SIBO (Small Intestinal Bacterial Overgrowth)
Depression
Candida
ADHD
No, I have never been diagnosed
Other, please specify
If Yes, when were you diagnosed?
4. Do you experience skin itching/irritation after food?
No
If Yes, please specify after which food or food combination and what symptoms do you experience
5. Have you recently been experiencing food sensitivity/allergies to food not previously experienced?
No
If Yes, please specify when, with which food, what do you experience?
6. Do you tolerate high fat diet/food?
Yes
No
7. Do you tolerate alcohol badly?
Yes
No
8. How do you feel after taking Kombucha tea and/or fermented vegetables?
9. How well do you tolerate milk and milk products (cheese, yogurt, kefir, etc)?
MOUTH CAVITY
1. Have you noticed any bleeding or tenderness in your gums during brushing or flossing?
Always
Sometimes
Rarely
Never
2. Do you experience bad breath?
Always
Sometimes
Rarely
Never
3. Have you ever been diagnosed with a gum disease, such as gingivitis or periodontitis?
No
If Yes, please specify which disease and when it was diagnosed
4. Do you use any gum or oral care products, such as mouthwash or gum stimulators, as part of your daily oral hygiene routine?
No
If Yes, please specidy which products are you using and reason why
5. Do you get sinus (nose) congestion?
Often
Sometimes
Rarely
Never
6. Have you ever had root canals treatment?
No
If Yes, please specify how many!
7. Do you grind teeth during night?
Yes
Sometimes
I had it in the past
No
SKIN
1. Do you have any skin issues?:
Psoriasis
Eczema
Rosacea
Acne
Itching
Rash
No, i don't have skin issues
If Yes, since when you have skin issues?
2. Do you get bruises easily?
Yes
No
3. Do you see any changes in mole(s)?
Yes
No
if Yes, please specify
4. Do you have dry or greasy skin, scalp, hair?
Greasy
Dry
Normal
5. Do you experience skin itching/irritation frequently?
No
If Yes, please describe
GENERAL
1. List of medications you take
Name Of Medicine
What do you take it for?
Does it help you with the symptoms?
Medicine 1
Medicine 2
Medicine 3
Medicine 4
Medicine 5
2. List of supplements
Name Of Supplements
What do you take it for?
Does it help you with the symptoms?
Supplement 1
Supplement 2
Supplement 3
Supplement 4
Supplement 5
3. Have you ever used corticosteroids?
*
Yes
No
4. Any history of surgeries or hospitalization? If so, please specify which and when?
5. Any additional comments about your health condition(diagnosis/symptoms/pain points, etc) and goal with this program - if yes please, specify:
6. What would you like to achieve with this program?
*
7. On a scale of 1 to 10 how important is this goal for you?
*
8. How fast would you like to reduce or completely remove all your mentioned symptoms:
*
As soon as possible
Within a few days
Over the next few weeks
In the next few months
As long as it need to feel myself again
If you have any laboratory tests (blood, urine, stool, hormone, etc.), or any document related to your health condition please attach them here:
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*
I understand and acknowledge that the questions asked above are not related to medical diagnosis, treatment, or recovery, and are not intended to identify, address, or cure any health condition. I further accept that if I fail to provide full, accurate, and detailed written information regarding my condition, Functional Health LLC, Sharjah, will not be held responsible for any outcomes resulting from incomplete disclosure.
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Thank you for taking the time to care for your health and well-being. Your dedication to this process is essential in achieving lasting results, and your input helps us provide the best possible support. We look forward to continuing this journey with you toward improved health and vitality.
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