Alqemis Health Questionnaire

1
Name
First Name
Last Name
2
What is your sex?
Please Select
Please Select
Female
Male
3
Date of Birth?MM-DD-YYYY
4
Phone Number Please include country code
5
Email
example@example.com
6
Address (US residents only)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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
7
If living outside of the US, please enter your mailing address below.
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Large
Normal
Small
Ok
Ok
8
What is your current height in inches?
9
What is your body weight in pounds?
10
Where were you born?(Please include the city as this gives our team insight on food and nutrients you may need to thrive.)
11
What do you do for work?Please include how long you have done this profession
12
Additional Birth infoInclude other relevant birth info, i.e. hospital or home birth, C-section or natural, premature or late, birth time.
13
Typical work schedule?
9am-5pm
Shift work
Graveyard
Unemployed
Condensed irregular (EMT, LEO, MD, or healthcare)
Entrepreneur (always working)
14
What is your number one health complaint?Please include how long this has been going on and how often it has been bothering you.
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Ok
15
What have you tried so far? Did it help?What changes have you seen progress with?
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16
How long has it been since you felt your best?
17
How often do you eat processed foods?
Never
Sometimes (few times per month)
Often (few times per week)
All the time
18
How often do you you eat organic fruits and vegetables?
Never
Sometimes (a few times per month)
Often (a few times per week)
All the time (3 or more servings each day)
19
How often do you you eat grass-fed and/or free-range meats and poultry?
Never
Once or twice a week
Few times per week
Three or more times a day
20
Do you follow a calorically restricted diet? If yes, how many calories?
21
Do you practice any of the following dietary restrictions?
I do not follow any dietary restriction
Carnivore Diet
Keto Diet
Low-carb
Low-fat
Paleo Diet
Vegetarian Diet
Vegan
22
Do you drink tap water?
Yes
No
Sometimes
Filtered only
23
How often do you prepare meals at home?
Never
Sometimes (few times per week)
Often ( 4-5 times per week)
Everyday
24
How often do you eat your meals at restaurants?
Never
Sometimes (few times per week)
Often (4-5 times per week)
Everyday
25
How often do you eat fast food?
Never
Sometimes (few times per week)
Often (4-5 times per week)
Everyday
26
How often do you eat dairy products?
Never
Sometimes (few times per week)
Often (almost everyday)
Multiple times per day
27
How often do you eat a variety of grains, excluding wheat?
Never
Sometimes (few times per week)
Often (almost everyday)
Multiple times per day
28
Are you aware of any foods that may be causing a reverse reaction to you?
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Small
Ok
Ok
29
What caffeinated beverages do you drink and how often?
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Small
Ok
Ok
30
How often do you drink alcohol?
Never
Occasionally (holidays or parties)
Often (three or more drinks per week)
Everyday
31
How often do you drink soda or other beverages with sugar?
Never or rarely
Sometimes (few times per week)
Often (more than 4 times per week)
Everyday
32
What is your general bed/wake time? Do you have an evening routine prior to bed? Examples include reading, meditating, limiting screen time, etc.
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Small
Ok
Ok
33
Do you sleep in a dark, cold room?Below 67°F / 19.4°C?
YESNO
34
Do you exercise less than three times per week?
Yes
No
Sometimes
35
Do you have intense or prolonged exercise sessions more than three times per week?
Yes
No
Sometimes
36
Is cardio a consistent part of your exercise routine?
YESNO
37
Do you have a sedentary lifestyle (outside of the gym)?
YESNO
38
Do you get up and move several times throughout the day?
Yes
No
Sometimes
39
How often is resistance or weight training a consistent part of your exercise routine?
Never or rarely
Sometimes (once or twice per week)
Often (more than three times per week)
Every session
40
Is walking a consistent part of your life?
YESNO
41
Is recreational drug use or vaping a part of your life?
Yes
No
Sometimes
42
Do you have a history of abuse or overuse of any of the following substances: drugs, alcohol or caffeine?
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Ok
43
Do you use tobacco?
Yes
No
Sometimes
44
Do you work overnight shifts/third shift or swing shifts?
YESNO
45
Do your work shifts last longer than 12 hours
Yes
No
Sometimes
46
Are you a workaholic?
Yes
No
Sometimes
47
Do you dedicate time for selfcare? 0 meaning never to 5 meaning all the time
Please Select
Please Select
0
1
2
3
4
5
48
Have you experienced acute stress, or been in a crisis in the past year (i.e. the loss of a loved one, employment and/or financial issues)?
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Small
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Ok
49
Have you experienced long periods of stress or trauma that has affected your wellbeing?
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Small
Ok
Ok
50
Is meditation a consistent part of your life?0 meaning never to 5 meaning always.
Please Select
Please Select
0
1
2
3
4
5
51
Are you a caregiver for a loved one?
YESNO
52
Do you have long work commutes?60 minutes or greater each way.
Yes
No
Sometimes
53
Do you work in hazardous conditions or have prolonged exposure to chemical, radiation, or biological dangers?
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Small
Ok
Ok
54
Are there any specific supplements that work well for you? Are there supplements that do not?Please list and explain
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Small
Ok
Ok
55
Are you currently under a physicians care?
YESNO
56
Have you ever had a serious illness?If yes, please explain.
57
Have you ever had any adverse reactions to vaccines or other medications?If yes, please explain.
58
When is your energy best during the day? When is it the worst?Description (optional)
59
Overall, is your energy good throughout the day?Description (optional)
60
Men only: Do you suffer from gynecomastia (enlarged breast tissue)?Description (optional)
61
Have you had COVID in any form?If yes, please explain.
62
What is your current COVID vaccination status?Description (optional)
63
Is there anything else medical that you would like to share with us?Description (optional)
64
Is there anything else in general that you would like to share with us?Description (optional)
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Ok
65
Please choose the following as it pertains to your GUT HEALTH:Choose ALL that apply to you
Constipation (defined as no Bowel Movement daily)
Diarrhea
Mucous in Stool
Blood in stool
Sulfer Burps
Pain after eating
Bloating after meals
Aversion to specific foods
Acid Reflux
Diarrhea right after meals
Nausea after meals
Excessive Gas
Dark/tarry stools
Craving Salt
66
Please choose the following as it pertains to your REPRODUCTIVE HEALTH:Choose ALL/ANY that apply to you Female questions = F, Male questions = M
Do you have normal cycles (every 21-28 days) F
Do you have heavy bleeding or anemia F
Do you ovulate consistently F
I have been pregnant before? F
I had issues with conceiving F
I take currently or have taken an oral contraceptive (birth control pill) F
I have had previous STDs M/F
I have been told I have low sperm count M
I have been told I have low testosterone M
I have an IUD F
I have been told that I have abnormal hormones M/F
I have had PCOS or think I have PCOS F
I am trying to conceive M/F
I am pregnant F
I am breastfeeding F
Other
67
Please choose the following as it pertains to your MEMORY and COGNITION:Choose all that apply to you
I experience headaches.
I need increased motivation to complete daily tasks.
I have a lack of daily motivation.
I am sensitive to light.
I can often feel overwhelmed with my daily tasks.
I have issues remembering daily things.
I have issues with recalling long term memories.
I have a family history of early onset dementia (defined as Dementia diagnosis in a family member younger than 60).
I feel that I have brain fog.
I have been told or have been diagnosed with Long COVID.
68
Please choose the following as it pertains to your SLEEP:Choose all that apply to you
I wake up feeling refreshed.
I DO NOT wake up feeling refreshed.
I am drowsy/very tired in the afternoon.
I have night sweats.
I snore.
I hold my breath while sleeping (apnea episodes).
I often wake between 2-3 am (not because of hunger).
I am very slow to "wake up" and get going in the morning.
I use over the counter sleep medications to help me get to sleep.
I use PRESCRIPTION/RX medications to help me get to sleep.
I have nightmares.
I dream very vivid dreams.
69
Please choose all of the following that pertains to your MENTAL HEALTH and MOOD:Choose all that apply to you.
I have Type A personality.
I have a difficult time calming down.
I get tearful easily.
I feel depressed.
I am easily angered or frustrated.
I have daily brain fog.
I have circular or obsessive thinking.
I startle easily.
I often feel dizzy or lightheaded.
I often behave aggressively.
I am hyperactive, jittery or nervous.
I have ADD or have severe difficulty creating and completing tasks.
I am mentally sluggish or feel spacey.
I feel overwhelmed daily.
70
Please choose all the following that apply to IMMUNITY:Choose any/all that apply to you
I am sick often.
I have been diagnosed with cancer.
tI have been told I have abnormal clotting or bleeding.
I bruise easily.
When I stand up or change body positions I get very dizzy.
I have a high resting heart rate.
I have coughs or colds that last for weeks.
I have been told that I have a chronic viral illness.
I have a previous diagnosis of Lyme disease.
Other
71
Please choose any of the following as it pertains to JOINT HEALTH and MUSCULOSKELETAL HISTORY:Choose all that apply to you
I have joint stiffness daily.
I have joint swelling.
I am easily injured in the gym or during fitness/activities/sports.
I feel that I have declining muscle mass.
I have everyday pain.
I have had major musculoskeletal/join/ligament injures that still cause me daily dysfunction and/or pain.
I feel/or have been told that I have poor circulation.
I have had surgery to repair broken bones and/or torn ligaments.
72
Please choose any of the following as it pertains to SKIN, HEAD, EAR, NOSE and THROAT:Choose all that apply to you.
Strong smells or fragrances cause headaches.
I have dental issues, gum disease or tooth decay.
I have brittle nails.
I have lines, ridges or dark spots on my nails.
I have oily skin.
I have acne on my face.
I have acne on my jaw line.
I have hair loss.
I have excessive dry eyes and mouth.
I have a sore throat often.
I have a dry cough.
I have thinning hair.
I have hair loss that is only patchy.
I have been told I have TMJ.
I clench or grind my teeth.
73
Do you agree to our terms of service?Terms of Service can be found in your welcome email.
YESNO
74
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