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Brandon Molle, FDN | Health Questionnaire
1
HE- Unique ID
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2
Full Name
First Name
Last Name
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3
Gender
Male
Female
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4
Date of Birth
-
Date
Month
Day
Year
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5
Place of birth (city, state, and country)
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6
Current Age
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7
Current Weight
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8
Current Height
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9
Mailing Address
Street Address
Street Address Line 2
City
State
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
United States
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
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10
Phone Number
Number you prefer to be reached at
Area Code
Phone Number
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11
May we text you at this number?
Yes
No
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12
E-mail
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13
Current Occupation(s)
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14
Previous Occupations
Please list any previous occupations lasting more than 1 year
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15
Marital Status
Single
Married
Domestic Partnership
Separated
Divorced
Widowed
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16
How did you hear about us?
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17
What are your top 5 main health complaints you experience regularly?
List in order of severity. These can also be health goals if you have few to no health complaints.
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18
Overall, how would you rate your current health?
Excellent
Good
Fair
Poor
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19
In your opinion, your overall health is...
getting better
getting worse
staying the same
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20
What markers do you use as a gauge to determine your level of health? Please list.
e.g. reduction of or disappearance of a symptom, energy levels, body shape, etc.
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21
Do you have any chronic (long-term or recurring) conditions? Please list.
e.g. inflammation, bad reactions to certain foods, kidney stones, skin issues, indigestion, etc.
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22
Do you have any diagnosed diseases, syndromes, or conditions, past or present? If so, please list.
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23
Do you have any genetic or congenital ("I was born with it") diseases, syndromes, or conditions? If so, please list.
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24
Have you had any operations? Please list, even if they are minor. If you had an organ, gland, or other body part removed, please note.
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25
Please list the 4 most stressful events in your life (deaths, divorces, financial hardships, accidents, etc.) Details are not necessary. Also list the approximate year they occured.
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26
What professionals have you visited so far to improve your health (e.g. traditional medical doctor, alternative medicine doctor, chiropractor, nutritionist, etc.)?
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27
Why did you choose to work with me?
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28
How are your major health complaints holding you back in life (family, career, charitable work, overall well-being, etc.)? In other words, what things are motivation for this decision to get to the root causes of your health complaints? Take some time to think about these. Don't rush.
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29
For our partnership to be a success in your eyes, what do you want to take place? In other words, what are your expectations?
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30
How long do you think it will take to reach your health and wellness goals?
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31
On a scale of 1-10, with 10 being 100% committed, what is your present level of commitment to address the root cause of your main health complaints?
Use the slider below
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32
On a scale of 1-10, with 10 being 100% confident, what is your present level of confidence in yourself to make the necessary changes to meet your health goals using this program?
Use the slider below
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33
If you are not a "10" in the confidence department, what obstacles do you think might hinder your progress?
We will address the obstacles during our work together, so don't worry!
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34
Who do you know that will help support you in your health goals?
List those people that build you up and support you in life.
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35
Check all that describe your energy levels during a typical day:
Takes a while for me to get going in the morning.
Low all the time
Up and down
Excessive and Hyper
Low after eating
Tired in the afternoon (after 2pm)
Really "hyped-up" at night / hard to relax
Normal and consistent
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36
Use the box below to list any supplements (multi-vitamin, fish oil, vitamin D, etc.) you are currently taking.
Include approximate amounts per day.
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37
Use the box below to list any prescriptions and over-the-counter drugs you are currently taking. Please spell the drug correctly, be sure to include exact dosages and why they were prescribed to you (what condition are they attempting to treat).
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38
What type of water comes into your home?
Tap / city / municipal water
Well water
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39
If you use well water, has the water been tested for safety within the last year?
Yes
No
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40
What type of water do you drink regularly?
Tap / city / municipal water
Well water
Water ran thru a filter
Bottled water
Other
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41
If you use a filter to purify the water that comes into your house, please list it below (some examples: Brita pitcher, reverse osmosis system, refrigerator filter, whole house system, Berkey filter, etc)
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42
Do you monitor how much water or other beverages you drink per day?
Yes, I do.
No, I don't.
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43
What type of water do you cook with?
Tap / city / municipal water
Well water
Water ran thru a filter
Bottled water
Other
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44
If you use a filter to purify the water that you shower or bathe with, please list it below.
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45
Youtube
Watch the video below for instructions on completing your diet journal.
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46
Do you think you eat a healthy diet?
Yes
No
Sometimes
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47
Do you typically have a strong craving for any of the following goods?
Check all that apply
Candy
Pastries, cookies, donuts
Dairy products (milk, cheese, ice cream)
Coffee
Alcohol
Soda / soft drinks
Chocolate
Fruit
Salty foods
Breads or pasta
Potatoes
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48
How often do you eat out at restaurants?
Once a month
Twice a month
Once a week
2 times a week
3 or more times per week
I don't eat out
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49
If you cook at home, what types of foods do you prepare?
Select all that apply
Boxed / pre-packaged
Frozen dinners
Made from scratch
Canned foods
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50
Do you use a microwave to heat foods or beverages?
Yes
No
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51
Do you store or heat foods in plastic containers?
Yes
No
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52
What type of cookware do you use?
Check all that apply
Stainless steel
Aluminum
Cast iron
Teflon-coated / non-stick
Glass
Ceramic
Enamel
Silicone
"Green" non-stick
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53
What if any special diets have you tried in the past (e.g. low fat, low carb, vegan, Akins, Mediterranean, Weight Watchers, etc)? Please list them here and note if any were successful in your mind.
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54
Do you have any known or suspected food allergies or food intolerances (i.e. gluten, milk, grains, etc)? If so, please list.
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55
Do you have a tendency to rush through your meals or eat very quickly?
Yes
No
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56
Do you tend to...
snack throughout the day
eat "three square meals"
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57
Do you tend to skip meals?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, which meal(s)?
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58
Do you have irregular eating times (i.e. more than 3 hours' deviation from a 6am breakfast, 12pm lunch, and 6pm dinner)?
Yes
No
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59
Do you drink more than 6 ounces of liquid with your meals?
Yes
No
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60
Do you get shaky, dizzy, tired, or irritable when you skip meals?
Yes
No
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61
Check all below that describe your digestion
Heartburn / Acid reflux
Burp / belch often
Bloating
Nausea
Poor appetite
Pain / burning in stomach
Lots of gas
Hiccup often
Very sleepy after meals
Meal sits very heavy / feel full for a long time
Have a bowel movement right after eating and sometimes see undigested food in stool
Headache after eating
No problems that I can tell!
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62
Youtube
This may not be required, so ask if you are in question.
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63
On average, how often do you have a bowel movement?
3 or more times per day
2 times per day
Once a day
Every other day
2 or more days in between
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64
What color is your stool?
You can choose more than one option
Medium brown
Dark brown or near black
Tan, grey or pale
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65
If your stool was a solid piece with the consistency and shape of a banana, how many inches long would it be?
2-4 inches
4-6 inches
6-10 inches
12 inches or more
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66
Describe your average bowel movement
You can choose more than one option
involves alot of pushing and straining
accompanied by lots of gas
pain or cramping
very foul/bad smelling
have to wipe excessively to get clean
usually tends towards constipation
usually tends toward diarrhea
stool sinks to the bottom
stool floats on top
stool contains blood
stool contains white or light-colored mucous
stool often contains undigested food
stool contains things I can't identify!
none of these...my bowel movements are pleasant and uneventful!
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67
Using the chart below, mark the pictures that most closely resemble your stools over the course of the last month. You can choose more than one type. If you have not been observing your stool for the last month, it's time to turn around and take a look! Take a peek and mark based on the next few days.
Hard pellets that resemble jelly beans or nuts
Firm and shaped like a lumpy nut-filled candy bar
Looks like corn-on-the -cob
Shaped like a snake, with a smooth surface
Soft with clear-cut edges, resembles chicken nuggets
Mushy like pudding
Watery with no solid form
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68
Do you have to use a laxative or an enema to have a bowel movement? If so, what kind and how often?
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69
How many times a day do you urinate?
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70
What is the typical color of your urine?
Clear
Light or pale yellow
Yellow
Dark yellow or amber
Fluorescent yellow (as when taking B vitamins)
Another color not listed above
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71
If applicable, select one or more of the following that describe your urination habits.
Sense of urgency
Too small amount (feels like I need to pee more but can't)
Too large amount (liquids run through me quickly and at great volume)
Burning
Dribbling
I get up to pee more than once per night (during normal sleeping hours)
I have had kidney stones or other kidney issues
I have had urinary tract infections (UTIs) and/or bladder infections
Incontinence (uncontrolled leaking or voiding of urine)
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72
At what age did you have your first period?
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73
Are you perimenopausal (transitioning into menopause)?
Please Select
Yes
No
Unsure
Please Select
Please Select
Yes
No
Unsure
If so, what age did this start?
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74
Are you menopausal (gone 12 consecutive months without a period)?
Yes
No
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75
If menopausal, at what age did your periods stop?
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76
If menopausal, check all symptoms you are experiencing.
Hot flashes
Vaginal dryness or irritation
Loss of libido (sex drive)
Insomnia
Depression
Night sweats
Mood swings
Weepy / Emotionally fragile
Hair loss
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77
If you are still menstruating, are your periods regular, meaning consistently between 27-30 days?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If no, how many days from the beginning of your period to the start of your next period?
How many days do you normally bleed?
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78
If you are still menstruating, please check all symptoms you experience around the time of your period (aka PMS).
Cramping
Bloating
Weakness / Fatigue
Heavy flow
Light flow
Spotting between periods
Bright red blood
Dark clotty blood
Mood swings
Weepy / Emotionally fragile
Irritability / Lack of patience
Back aches
Painful or tender breasts
Water retention
Headaches
Food cravings
Constipation and/or diarrhea
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79
Do you currently use birth control?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, what method?
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80
Do you use birth control in the past?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, what method and for how long?
How long ago did you stop?
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81
Pregnancies
Total number
Number of children
Number of miscarriages
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82
Describe any pregnancy or childbirth complications
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83
After having children, did your overall health
improve
stay the same
worsen
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84
Have you had an hysterectomy or any other gynecological operations?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please describe.
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85
Regarding sleep
What time do you go to sleep?
What time do you usually wake up?
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86
How many hours sleep (on average) do you get a night?
If you wake alot during the night, add the hours of sleep together and give me a total.
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87
Check all that apply when it comes to your sleep
I have trouble falling asleep
I wake up alot at night
I have bad dreams often
I have night sweats
I'm restless and toss and turn
I wake up tired
I get leg cramps and/or achy legs
I snore
I use a CPAP machine
I have or suspect I have sleep apnea
I often wake between 2am and 3am
I often wake up during the night and am hungry and need to eat
I have racing thoughts before bed
I get up to pee at least once per night
My partner, children, or pets wake me often or prevent a good night's rest for me
I often get texts or alerts on my phone that wake me during the night
I sleep soundly through the night
I wake up refreshed
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88
Describe your typical pre-bedtime routine (reading, watching television, working, bubble bath, etc).
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89
Do you sleep in a completely dark room (very little to no light)?
Yes
No
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90
Do you perform shift work (second shift, third shift, swing shift, etc)?
Yes
No
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91
Do you turn off Wi-Fi (wireless internet) at night before bed?
Yes
No
I don't have Wi-Fi
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92
Do you sleep with a cell phone, tablet, computer, alarm clock, or other electronic device within 10 feet of your body?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list which device(s).
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93
Describe what you do to rest during a typical week. This is not sleeping or napping, but activities unlike your daily work schedule, like laying on the couch or hammock and reading a book or watching tv, sitting outside enjoying nature or a sunset, sunbathing, engaging in relaxing conversation with loved one or friend, working a puzzle, etc. If you never engage in these activities, then tell me this also.
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94
Do you ever take a nap or want to take a nap?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, describe your naps.
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95
Do you like to exercise?
Yes, which way to the gym!
No way! Have to force myself to do it and I hate every minute of it.
I like the results I get, but don't enjoy the process.
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96
What types of exercise do you engage in currently, and how frequently?
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97
How much exercise do you feel you are doing?
Too little
Too much
Just the right amount
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98
Do you feel like your exercise program is benefitting you?
Please Select
Yes
No
Not sure how to evaluate
Please Select
Please Select
Yes
No
Not sure how to evaluate
Please explain
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99
How many hours per week are you outside getting sun exposure?
In the summer
In the winter
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100
How many hours a day do you spend under artificial or fluorescent light?
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101
Do you try to get some sun exposure daily, especially first thing in the morning?
Yes
No
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102
How does your skin react to the sun?
Burn easily and never get tan
Get red, but red turns to tan
Tan very easily, rarely burn
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103
List the brand of each of the following Personal Care Products you currently use. Check your cabinets to make sure you have listed the correct brand. If you don't use a particular product, just leave it blank.
Shampoo
Toothpaste
Bath Soap
Lotion
Deodorant
Face make-up
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104
List the brand of each of the following Household Cleaning Products you currently use. Check your cabinets to make sure you have listed the correct brand. If you don't use a particular product, just leave it blank.
Laundry detergent
Liquid dishwashing soap
Fabric softener
Automatic dishwashing soap
Bathroom cleaner
All-purpose kitchen cleaner
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105
Have you ever visited a chiropractor, massage therapist, acupuncturist, or other bodywork practitioner?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list who you saw, if the treatment was effective, and if continue to see them today.
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106
Do you currently smoke tobacco or chew tobacco?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list which one (on both).
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107
How much do you smoke or chew per day?
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108
How long have you used tobacco?
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109
If you don't currently use tobacco, did you smoke in the past?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, how many years did you use?
And how long ago did you quit?
How did you quit (will power, patch, gum, prescription, hypnosis)?
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110
Do you have a history of alcohol abuse or binge drinking?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please describe.
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111
How many alcoholic beverages to you consume per week?
None
1-2
3-4
5 or more
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112
Do you have a history of drug abuse (prescription or street drugs)?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please describe.
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113
Do you currently use recreational drugs?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list type and frequency.
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114
Have you ever had toxic chemicals spill on your body or regularly exposure your bare skin to chemicals like at your job?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please explain.
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115
Check any of the jobs you've held for at least 6 months. If any of the following are hobbies, please mark those too.
Farmer
Insect / Pest Exterminator
Factory Maintenance Worker
Janitor
Painter
Golf Course or Lawn Maintenance
Dentist
Water Treatment
Hair Stylist
Furniture Refinishing
Dry Cleaner
Trash Collector
Radiologist
Metal working
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116
Have you traveled outside the United States?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list location and approx. dates.
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117
Have you ever been administered IV antibiotics?
Yes
No
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118
Have you ever taken oral (pill or liquid) antibiotics?
Yes
No
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119
Have you ever been exposed to mold in a home or workplace?
Yes
No
I'm not sure.
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120
Is your home or workplace regularly treated for insects?
Yes
No
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121
Do you have indoor pets?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, do they sleep in your bed?
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122
Do you use an air purifier in your home?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, what kind or brand?
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123
Are you sensitive to strong odors (e.g. perfumes, detergents, cigarette smoke, car exhaust)?
Yes
No
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124
Do you suffer from skin rashes or hives, for which the cause is unknown?
Yes
No
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125
Do you have any of the following?
Check all that apply
Amalgams (silver fillings)
Gold crowns or inlays
Stainless steel crowns or inlays
Composites (tooth-colored)
Root canals
Bridge
Veneers
Gum infections
Bleeding gums
Sensitive teeth
Bad breath
Tooth pain
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126
Do you need further dental work?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, what?
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127
Mark all electronic devices that are in close proximity to your body (less than 3 feet away) for more than 2 hours per day.
Desktop computer
Laptop computer
Tablet
Cell phone
Wired headset
Wireless headset (like call center)
Wireless Bluetooth headset
Hearing aid
Copy machine
Wireless router or repeater
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128
Do you have Wi-Fi (wireless internet) in your home or place of employment?
Yes
No
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129
Do you have any body piercings?
Please Select
Yes
No
Please Select
Please Select
Yes
No
If yes, please list.
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130
How would you rate your overall stress level (1-10, with 10 being the highest)?
Type a number from 1-10.
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131
What are your main sources of stress (e.g. financial, relational, existential, etc)?
Please briefly describe here.
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132
Explain some ways you are attempting to reduce your stress level or are coping with stress. Say whether or not you think these measures are working or if you are choosing healthy ways to cope.
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133
When was your last vacation and what did you do during it?
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134
Check the most prevalent feelings you have throughout a typical week.
Choose all that apply
Happy
Easy-going / Relaxed
Peaceful
Hopeful
Confident
Compassionate
Loved
Focused
Secure
Thankful / Grateful
Worried
Anxious / Nervous
Depressed
Guilty
Restless
Indecisive
Angry
Desire to be alone
Lonely
Rushed / Behind schedule
Hopeless / Despairing
Irritable / Grumpy
Apathetic / Lacking passion
Distracted
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135
What are your Top 3 main goals or highest priorities in life?
#1
#2
#3
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136
Where do you see yourself in 5 years (family, career, charitable work, health-wise, financially, etc.)?
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137
Do you feel your life has meaning? Have you found a purpose(s) for living?
Please explain.
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138
Do you consider yourself a spiritual person?
Please explain.
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139
Do you believe in a power or being higher than yourself? If so, what is your opinion of him/her/it and do they have any influence in your life?
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