Health Questionnaire

Ignite the Healer Within
Health Questionnaire

Personal Information
Date
Full Name

First NameLast Name
Height
Weight
Age
Anatomy
Birth Date

MonthDayYear
Birth Time

:HourMinutesAM/PM Option
Birth Location
City, State, Country
Eye Color
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number

Area CodePhone Number
Skype Screen Name
Family Physician and Phone #
Vitals
Blood Pressure

Left SideRight Side
Pulse
Respirations
Basal Temperature
pH

UrineSaliva
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?
Is it easy to put on weight and hard to lose it?
Are your fingernails ridged, brittle or weak?
Do you have varicose or spider veins?
Do you, or have you had hemorrhoids or prolapsed organs?
Do you get cramping in your muscles?
Is your bladder strong or weak?
Do you have an irregular heartbeat?
Do you have Mitral Valve Prolapse (Heart Murmur)?
Do you get headaches or migraines?
Have you ever had a hernia?
Have you ever had an aneurysm?
Do you have osteoporosis?
Do you have scoliosis?
Do you get irritable easily?
Do you have low energy levels?
Do you suffer from symptoms of depression?
Did you score low on your bone density tests?
Do your tests come back showing low Calcium levels?
Do you have, or have you ever had, a goiter?
Do you have spine deterioration, herniated discs, or bone spurs?
Have you been diagnosed with Hashimoto or Reidel disease? Has a family member?
How much do you sweat?
Do your legs get tired or cramp after you walk?
Do you bruise easily? (parathyroid)
Pancreas
Do you get gas after you eat?

Other
Do you feel your foods just sitting in your stomach?
Do you have Acid Reflux?
Do you see any undigested foods in your stools?
Are you thin and have a hard time putting on weight?
Do your foods pass right through you (diarrhea)?
Do you have moles on your body? (Adrenal & Pancreatic weakness)
Adrenal Glands
Medulla (Adrenal)
Are you overweight?
Do you have M.S., Parkinson's or Palsy?
Do you have anxiety attacks, or feel overly anxious?
Do you feel excessive shyness or inferior to others?
Do you have tremors, nervous legs, etc.?
Do you have High or Low Blood Pressure?
Blood pressure: ex 120/60
Do you have hypoglycemia (low blood sugar)?
Do you have Diabetes (high blood sugar)?
Do you have tinnitis (ringing in the ears)?
Do you have shortness of breath or is it hard to take a deep breath?
Do you have heart arrhythmias?
Do you have a hard time sleeping or insomnia? (pineal)
Do you have Chronic Fatigue Syndrome?
Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia?
Cortex (Adrenal)
Do you have elevated blood cholesterol levels?
Do you have arthritis, bursitis, or any inflammatory issues?

Other
Do you have any "itis' (inflammatory conditions)?
Explain
Do you have low steroids or cortisol levels?
Females Only
Are your menstruation's irregular? (pituitary)
Do you get excessive bleeding during menstruation?
Do you have or have you had ovarian cysts?
Do you have or have you had fibroids?
Do you have or have you had endometriosis or A-typical cells?
Do you have or have you had fibrocystic breasts?
Do you get sore breasts, especially during menstruation?
Do you have a low or excessive sex drive?
Have you had a hysterectomy?
If yes, Date and State if Partial or Full
Did they take any other organs out at the same time? (ie gallbladder)
If yes, what other organs?
Have you had a D & C?
Have you had a miscarriage?
Have you had a difficulty conceiving children?
Have you been on Birth Control Pills?
If yes, for how long?
Are you currently pregnant?
Males Only
Do you have prostatitis (frequent urination esp. at night)?
If yes, how often do you urinate?
Do you have prostate cancer?
If yes, What are your PSA counts?: And Date:
Do you have testicular hypertrophy (enlargement)?
Do you have a low or excessive sex drive?
Do you have erection problems?
Do you have premature ejaculation?
Gastro-Intestinal Tract
Do you have gastritis or enteritis?
Is your tongue coated (white, yellow, green, or brown), especially in the morning?
Do you have gastroparesis?
Do you have a hiatus hernia?
Do you have colitis?
Do you have diverticulitis?
Do you get or have diarrhea?
Do you get or have constipation?
have you ever had stomach or intestinal ulcers?
Do you or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal, etc.)
If yes, explain:
Do you have Crohn's Disease?
Do you have "gas" problems?
Other GI problems:
Liver/Gallbladder/Blood
Do you have a problem digesting fats?
Do fats or dairy foods cause bloating and/or pain in the stomach area?
Are your stools white or very light brown in color?
Do you get pain behind the right, lower rib area?
Do you have "liver" or brown spots on your skin? (not freckles)
Are you jaundiced (yellowing of the skin)?
Do you have any skin pigmentation changes?
Are you or have you ever been anemic?
Do you have, or have you ever had, hepatitis?
If yes, please indicate A, B, or C:
Heart and Circulation
Do you get chest pains or angina?
Have you ever had a heart attack (Myocardial Infarction)?
Have you ever had open-heart surgery?
Do you have heart arrhythmia's?
If so, what kind?
Do you have a heart murmur or Mitral Valve Prolapse?
Do you ever feel pressure on your chest?
Do you get "prickly" pains anywhere, especially in the heart area?
If so, Where?
Do you have, or have you ever had High Blood Pressure? (kidneys)
Do you have a Pacemaker or Stints?
Skin
Do you get or have skin rashes?
Do you get skin blemishes?
Do you have Eczema or Dermatitis?
Do you have Psoriasis?
Do you itch anywhere?
If so, where?
Is your skin:
Do you get or have dandruff?
Do you have skin problems?
If so, what type:
Lymphatic System
Do you have hair loss or are you bald or going bald?
Have you ever had lymph nodes removed?
Do you have, or have you ever had, a goiter?
Do you have any gray hair?
Do you have a hard time remembering things?
Do you ever get colds or flu-like symptoms?
Do you have fibromyalgia or scleroderma?
Do you have sinus problems?
Do you have or get sore throats?
Do you have swollen lymph nodes?
Do you have or have you had tumors?
If so, where?
Type
Do you have a low platelet count (blood)?
Is your immune system weak or sluggish?
Have you had appendicitis or an appendectomy?
When?
Do you get boils, pimples, cysts, etc.?
Do you get regular exercise?
How many times per week?
Have you ever had abscesses?
Have you ever had toxemia?
Do you have, or have you had, cellulitis?
Have you ever had gout?
Do you get blurred vision?
Do you have mucus in your eyes when you wake up in the morning?
Do you snore?
Do you have sleep apnea?
Have you had your tonsils out?
What age?
Kidneys and Bladder
Have you ever had a urinary tract infection (UTI's)?
Have you ever had "burning" upon urination?
Do you have problems holding your bladder? (parathyroid)
Have you ever had kidney stones?
Do you have bags under your eyes (esp. in the morning)?
Is your urine flow restricted?
Do you get cramping or pain on either side of your mid-to-lower back?
Do you or did you ever have nephritis?
Do you have lower back weakness?
Do you have or have you had sciatica?
Do you or did you ever have cystitis?
Lungs
Do you get or have (or have had) any of the following?:
Are you on inhalers or nebulizers?
How often?
What type?
Oxygen saturation level?
Do you get pain when you breathe?
Is it difficult to take a deep breath? (adrenals)
Did you ever or do you have lung cancer?
Do you have a collapsed lung?
Are you a smoker?
If yes, of cigarettes or marijuana?
How much per day?
Have you ever had pneumonia?
Have you ever worked around toxic chemicals, in coal mines, or around asbestos?
Do you cough a lot?
Do ou get any mucus when you cough?
What color is the mucus?
Environmental Toxins
Have you been vaccinated?
Have you had shots for traveling to foreign countries?
Have you had Flu shots?
Do you have mercury amalgams?
Do you find it difficult to take deep breaths?
Have you been exposed to any of the following:
If yes to above, please elaborate:
Have you had radiation or chemotherapy?
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):
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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!!