Health Questionnaire
Personal Information
Date
-
Month
-
Day
Year
Date
Full Name
First Name
Last Name
Height
Weight
Age
Gender
Male
Female
Birth Date
-
Month
-
Day
Year
Date
Eye Color
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Skype Screen Name
Family Physician
First Name
Last Name
Family Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Vitals
Blood Pressure
Left Side
Right Side
Pulse
Respirations
Basal Temperature
pH
Urine
Saliva
How many bowel movements do you have per day?
*
What does your diet consist of?
Thyroid/Parathyroid (Glandular System)
Do you get cold hands and feet?
Yes
No
Is it easy to put on weight and hard to lose it?
Yes
No
Maybe
Are your fingernails ridged, brittle or weak?
Ridged
Brittle
Weak
None of the above
Do you have varicose or spider veins?
Yes
No
Do you, or have you had hemorrhoids or prolapsed organs?
Hemorrhoids
Prolapsed organs
No
Do you get cramping in your muscles?
Yes
No
Do you have an irregular heartbeat?
Yes
No
Is your bladder strong or weak?
Strong
Weak
Do you have Mitral Valve Prolapse (Heart Murmur)?
Yes
No
Do you get headaches or migraines?
Yes
No
Have you ever had a hernia?
Yes
No
Do you have osteoporosis?
Yes
No
Have you ever had an aneurysm?
Yes
No
Do you have scoliosis?
Yes
No
Do you get irritable easily?
Yes
No
Do you have low energy levels?
Yes
No
Do you suffer from symptoms of depression?
Yes
No
Did you score low on your bone density tests?
Yes
No
Do your tests come back showing low Calcium levels?
Yes
No
Do you have, or have you ever had, a goiter?
Yes
No
Do you have spine deterioration, herniated discs, or bone spurs?
Yes
No
Have you been diagnosed with Hashimoto or Reidel disease? Has a family member?
Yes
No
Family member
How much do you sweat?
Low
Medium
A lot
Do your legs get tired or cramp after you walk?
Yes
No
Do you bruise easily? (parathyroid)
Yes
No
Pancreas
Do you get gas after you eat?
Yes
No
Do you feel your food just sitting in your stomach?
Yes
No
Do you have Acid Reflux?
Yes
No
Do you see any undigested foods in your stools?
Yes
No
Are you thin and have a hard time putting on weight?
Yes
No
Do your foods pass right through you (diarrhea)?
Yes
No
Do you have moles on your body? (Adrenal & Pancreatic weakness)
Yes
No
Adrenal Glands
Medulla (Adrenal)
Are you overweight?
Yes
No
Do you have M.S., Parkinson's, or Palsy?
Yes
M.S.
Parkinson's
Palsy
No
Do you have anxiety attacks, or feel overly anxious?
Yes
No
Do you feel excessive shyness or inferior to others?
Yes
No
Do you have tremors, nervous legs, etc.?
Yes
No
Do you have High or Low Blood Pressure?
High
Low
Average
Blood pressure: ex 120/60
Do you have hypoglycemia (low blood sugar)?
Yes
No
Do you have Diabetes (high blood sugar)?
Yes
Type I
Type II
No
Do you have tinnitus (ringing in the ears)?
Yes
No
Do you have shortness of breath or is it hard to take a deep breath?
Yes
No
Do you have heart arrhythmias?
Yes
No
Do you have a hard time sleeping or insomnia? (pineal)
Yes
No
Do you have Chronic Fatigue Syndrome?
Yes
No
Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia?
Yes
Addison's
Congenital Adrenal Hyperplasia
No
Cortex (Adrenal)
Do you have elevated blood cholesterol levels?
Yes
No
Do you have arthritis, bursitis, or any inflammatory issues?
Yes
No
Do you have any "itis' (inflammatory conditions)?
Yes
No
Explain
Do you have low steroids or cortisol levels?
Yes
No
Females Only
Is your menstruation irregular? (pituitary)
Yes
No
Do you get excessive bleeding during menstruation?
Yes
No
Do you have or have you had ovarian cysts?
Yes
No
Do you have or have you had fibroids?
Yes
No
Do you have or have you had endometriosis or A-typical cells?
Yes
No
Do you have or have you had fibrocystic breasts?
Yes
No
Do you get sore breasts, especially during menstruation?
Yes
No
Do you have a low or excessive sex drive?
Low
Excessive
Average
Have you had a hysterectomy?
Yes
No
If yes, Date and State if Partial or Full
Did they take any other organs out at the same time? (ie gallbladder)
Yes
No
If yes, what other organs?
Have you had a D & C?
Yes
No
Have you had a miscarriage?
Yes
No
Have you had a difficulty conceiving children?
Yes
No
Have you been on Birth Control Pills?
Yes
No
If yes, for how long?
Are you currently pregnant?
Yes
No
Males Only
Do you have prostatitis (frequent urination esp. at night)?
Yes
No
If yes, how often do you urinate?
Do you have prostate cancer?
Yes
No
If yes, What are your PSA counts?: And Date:
Do you have testicular hypertrophy (enlargement)?
Yes
No
Do you have a low or excessive sex drive?
Low
Excessive
Average
Do you have erection problems?
Yes
No
Do you have premature ejaculation?
Yes
No
Gastro-Intestinal Tract
Do you have gastritis or enteritis?
Yes
No
Is your tongue coated (white, yellow, green, or brown), especially in the morning?
Yes
No
Do you have gastroparesis?
Yes
No
Do you have a hiatus hernia?
Yes
No
Do you have colitis?
Yes
No
Do you have diverticulitis?
Yes
No
Do you get or have diarrhea?
Yes
No
Do you get or have constipation?
Yes
No
have you ever had stomach or intestinal ulcers?
Yes
No
Do you or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal, etc.)
Yes
No
If yes, explain:
Do you have Crohn's Disease?
Yes
No
Do you have "gas" problems?
Yes
No
Other GI problems:
Liver/Gallbladder/Blood
Do you have a problem digesting fats?
Yes
No
Do fats or dairy foods cause bloating and/or pain in the stomach area?
Yes
No
Are your stools white or very light brown in color?
Yes
No
Do you get pain behind the right, lower rib area?
Yes
No
Do you have "liver" or brown spots on your skin? (not freckles)
Yes
No
Are you jaundiced (yellowing of the skin)?
Yes
No
Do you have any skin pigmentation changes?
Yes
No
Are you or have you ever been anemic?
Yes
No
Do you have, or have you ever had, hepatitis?
Yes
No
If yes, please indicate A, B, or C:
Heart and Circulation
Do you get chest pains or angina?
Yes
No
Have you ever had a heart attack (Myocardial Infarction)?
Yes
No
Have you ever had open-heart surgery?
Yes
No
Do you have heart arrhythmia's?
Yes
No
If so, what kind?
Do you have a heart murmur or Mitral Valve Prolapse?
Yes
No
Do you ever feel pressure on your chest?
Yes
No
Do you get "prickly" pains anywhere, especially in the heart area?
Yes
No
If so, Where?
Do you have, or have you ever had High Blood Pressure? (kidneys)
Yes
No
Do you have a Pacemaker or Stints?
Yes
Pacemaker
Stints
No
Skin
Do you get or have skin rashes?
Yes
No
Do you get skin blemishes?
Yes
No
Do you have Eczema or Dermatitis?
Yes
No
Do you have Psoriasis?
Yes
No
Do you itch anywhere?
Yes
No
If so, where?
Is your skin:
Dry
Oily
Combo
Do you get or have dandruff?
Yes
No
Do you have skin problems?
Yes
No
If so, what type:
Lymphatic System
Do you have hair loss or are you bald or going bald?
Yes
No
Have you ever had lymph nodes removed?
Yes
No
Do you have, or have you ever had, a goiter?
Yes
No
Do you have any gray hair?
Yes
No
Do you have a hard time remembering things?
Yes
No
Do you ever get colds or flu-like symptoms?
Yes
No
Do you have fibromyalgia or scleroderma?
Yes
No
Do you have sinus problems?
Yes
No
Do you have or get sore throats?
Yes
No
Do you have swollen lymph nodes?
Yes
No
Do you have or have you had tumors?
Yes
No
If so, where?
Type
Fatty
Benign
Malignant
Do you have a low platelet count (blood)?
Yes
No
Is your immune system weak or sluggish?
Yes
No
Have you had appendicitis or an appendectomy?
Yes
No
When?
Do you get boils, pimples, cysts, etc.?
Yes
No
Do you get regular exercise?
Yes
No
How many times per week?
Have you ever had abscesses?
Yes
No
Have you ever had toxemia?
Yes
No
Do you have, or have you had, cellulitis?
Yes
No
Have you ever had gout?
Yes
No
Do you get blurred vision?
Yes
No
Do you have mucus in your eyes when you wake up in the morning?
Yes
No
Do you snore?
Yes
No
Do you have sleep apnea?
Yes
No
Have you had your tonsils out?
Yes
No
What age?
Kidneys and Bladder
Have you ever had a urinary tract infection (UTI's)?
Yes
No
Have you ever had "burning" upon urination?
Yes
No
Do you have problems holding your bladder? (parathyroid)
Yes
No
Have you ever had kidney stones?
Yes
No
Do you have bags under your eyes (esp. in the morning)?
Yes
No
Is your urine flow restricted?
Yes
No
Do you get cramping or pain on either side of your mid-to-lower back?
Yes
No
Do you or did you ever have nephritis?
Yes
No
Do you have lower back weakness?
Yes
No
Do you have or have you had sciatica?
Yes
No
Do you or did you ever have cystitis?
Yes
No
Lungs
Do you get or have (or have had) any of the following?:
Bronchitis
Emphysema
Asthma
C.O.P.D.
Are you on inhalers or nebulizers?
Yes
No
How often?
What type?
Oxygen saturation level?
Do you get pain when you breathe?
Yes
No
Is it difficult to take a deep breath? (adrenals)
Yes
No
Did you ever or do you have lung cancer?
Yes
No
Do you have a collapsed lung?
Yes
No
Are you a smoker?
Yes
No
If yes, of cigarettes or marijuana?
How much per day?
Have you ever had pneumonia?
Yes
No
Have you ever worked around toxic chemicals, in coal mines, or around asbestos?
Yes
No
Do you cough a lot?
Yes
No
Do ou get any mucus when you cough?
Yes
No
What color is the mucus?
Clear
Yellow
Green
Brown
Black
Environmental Toxins
Have you been vaccinated?
Yes
No
Have you had shots for traveling to foreign countries?
Yes
No
Have you had Flu shots?
Yes
No
Do you have mercury amalgams?
Yes
No
Do you find it difficult to take deep breaths?
Yes
No
Have you been exposed to any of the following:
Nuclear Wastes or by-products
Heavy Metals
Chemicals
If yes to above, please elaborate:
Have you had radiation or chemotherapy?
Radiation
Chemotherapy
No, I haven't
If so, how many treatments?
Chemical Medications
List any medications you are currently taking
Medication Names and Reason for taking:
Natural Supplements you are on currently
Allergies
Past Surgeries - major and minor, and the year
Genetic/Family Medical History
Mother
Father
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
Sister(s)
Brother(s)
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What are your major health concerns (please list anything that was not addressed in this questionnaire):
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