Health Questionnaire

Ignite the Healer Within
Health Questionnaire

Personal Information
Date
Full Name *

First Name Last Name
Height
Weight
Age
Female-Male

Female Male Transgender
Birth Date

Month Day Year
Eye Color
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number

Area Code Phone Number
Skype Screen Name
Family Physician and Phone #
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
Is your bladder strong or weak?

Strong Weak
Do you have an irregular heartbeat?

Yes No
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
Have you ever had an aneurysm?

Yes No
Do you have osteoporosis?

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 N/A
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 foods 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 tinnitis (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
Are your menstruation's 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)
You are almost done!!
What are your major health concerns (please list anything that was not addressed in this questionnaire):
Option to upload any document you feel is relevant
Option to attach eye photo
Option to attach eye photo
Thank you!!
Should be Empty:

Health Questionnaire

Vitals

Thyroid/Parathyroid (Glandular System)

Pancreas

Adrenal Glands

Females Only

Males Only

Gastro-Intestinal Tract

Liver/Gallbladder/Blood

Heart and Circulation

Skin

Lymphatic System

Kidneys and Bladder

Lungs

Environmental Toxins

Chemical Medications

Genetic/Family Medical History

You are almost done!!

Thank you!!