Name:__________________________________________________                    Date: ____/____/_____            DOB:___________                     Gender:_____________

Address_______________________________________________________________________________________________________________________________

______________________________________________________________________________________          Contact Number:_____________________________

Profession __________________________________________________________________________

Please list your five major health concerns in order of importance:

1_____________________________________________________________________________________________________

2_____________________________________________________________________________________________________

3_____________________________________________________________________________________________________

4_____________________________________________________________________________________________________

 

Part 1

Read the following questions and fill in the number which applies (Key: 0=do not consume/use; 1=consume/use 2–3 times a month; 2=consume/use weekly; 3= consume/use daily                           _________________________________________________________________________________DIET

1 ___ Alcohol

2 ___ Artificial Sweeteners

3____ Sweets/crisps

4 ____fizzy drinks

5 ____ chewing tobacco

6 ____ cigarettes

7 ____ cigar/pipe

8  ____coffee

9 ____ fast food

10____fried food

11___ luncheon meats

12 ___margarine

13 ___ milk products

14 ___Margarine

15 ___refined flour/baked goods

16 ___refined sugar

17 ___vitamins and minerals

18 ___water distilled

19 __ water tap

20 ___ water well

21 ___ often diet

_________________________________________________________________________________

LIFESTYLE

22_____   times you exercise per week (0=never; 1= once a week; 2= 2-4 times a week; 3= 5 times a week)

23 _____ changed jobs (0= no;1=within last 12 months; 2= within last 6 months; 3= within last 2 months)

24 _____ divorced (0=no; 1= within last 2 years; 2= within last year; 3= within last 6 months)

 

MEDICATIONS: INDICATE WITH A TICK ANY MEDICATIONS YOU ARE CURRENTLY TAKING OR HAVE TAKEN WITHIN LAST MONTH

26____Antacids

27____Antibiotics

28____Anticonvulsants

29____Antidepressants

30____Antifungals

31____Aspirin/ Ibuprofen

32 ____Asthma inhalers

33____Beta blockers

34 ___ Chemotherapy

35____Cortisone

36___ _Diabetic             medication

37____Diuretics

38____Estrogen/ Progesterone

39____Heart medications

40____High blood pressure

41____Hormone therapy

42____Laxatives

43 ____Insulin

44____Oral/ Implant contraceptives

45____Radiation exposure

46 ____Recreational drugs

47____Relaxants/sleeping pills

48____Thyroid medication

49____Tylenol/Acetaminophen

50 ___ Ulcer medication

 

 

Part 2

 

specific medication and dose information: __________________________________________________________________________________________________________________________________________________________________________________________________________________

Read the following and fill in the number that applies

(Key: 0= no/ do not have symptoms; 1= yes or it is a minor or mild symptom or it occurs once a month or less; 2= it is a moderate symptom or it occurs once a week; 3= it is a severe symptom or it frequently occurs (daily))

______________________________________

Section 1

51 ___ belching or gas within 1 hr of eating meal

52 ___ heartburn or acid reflux

53 ___ bloating shortly after eating

54 ___ Follow a vegan diet (no dairy, meat, fish or     eggs

55 ___ bad breath (halitosis)

56 ___ Loss of taste for meat

57 ___ Sweat has a strong odour

58 ___ Stomach upset by taking vitamins

59 ___ Sense of excess fullness after eating

60 ___ Do you feel like skipping breakfast

61 ___ Do you feel better if you don’t eat

62 ___ Sleepy after meals

63 ___ Fingernails chip, peel or break easily

64 ___ Anaemia unresponsive to iron

65 ___ Stomach pains or cramps

66 ___ Diarrhoea,  chronic

67 ___ Diarrhoea shortly after meals

68 ___ Black or tarry stools

Section 2

70 ___ Pain between shoulder blades

71 ___ Stomach upset by greasy foods

72 ___ Greasy or shiny stools

73 ___ Nausea

74 ___ Sea, car or airplane sickness, motion sickness

75 ___ History of morning sickness (1=yes; 0=no)

76 ___ Light or clay coloured stools

77 ___ dry skin, itchy feet and / or skin peels on feet

78 ___ Headache over the eye

79 ___ gallbladder attacks past or present

80 ___ Gallbladder removed (0= no; 1=yes)

81 ___ Bitter taste in mouth, especially after meals

82 ___ become sick if drinking wine

83 ___ If drinking alcohol, easily intoxicated

84 ___ alcoholic beverages per week (0= <3/week;

1= <7/week; 2=<14/week; 3=>14/week)

85___ recovering alcoholic (0=no; 1=yes)

86 ___ hangovers after drinking alcohol

 

 

 

 

 

87 ___ history of drug/ alcohol abuse (0=no;1=yes)

88 ___ History of hepatitis (0=no; 1=yes)

89 ___ Long term use of prescription medications

(0=no; 1=yes)

90 ___ Sensitive to chemicals (perfume, cleaning      solvents, insecticides, exhaust etc)

91 ___ sensitive to tobacco smoke

92 ___exposure to traffic pollutants

93 ___ Pain under right side of rib cage

94 ___ haemorrhoids or varicose veins

95 ___ nutrasweet (aspartame) consumption

96 ___ bothered by aspartame (nutrasweet)

97 ___ Chronic fatigue or Fibromyalgia

98  ___ Food allergies

99  ___ Abdominal bloating 1 to 2 hours after eating

100 ___ Specific foods make you tired or bloated

(0=no; 1=yes)_______________(food)

101 ___ Pulse speeds after eating

102 ___ Airborne allergies

103 ___ Experience hives

104 ___ Sinus congestion stuffy head

105 ___ Crave bread or noodles

106 ___ Alternating constipation and diarrhoea

107 ___ Crohn’s  Disease (0=no; 1=yes)

108 ___ Wheat or grain sensitivity

109 ___ Dairy sensitivity

110 ___ Are there foods you couldn’t give up

(0=no; 1=yes)

111 ___ Asthma, sinus infections, stuffy nose

112 ___ Bizarre vivid or nightmarish dreams

113 ___ Use over the counter pain medications

Section 4

115 ___ Anus itches

116 ___ Coated tongue

117 ___ Feel worse in mouldy or musty place

118 ___ Taken any antibiotic for a combined time of

(0=no; 1= <1mo; 2=<3mos; 3= >3mos)

119 ___ Fungus or yeast infections

120 ___ Ring worm, jock itch, athletes foot, nail

Fungus

121 ___ Eating sugar, starch or drinking alcohol           increases yeast symptoms

122 ___ Stools hard or difficult to pass

123 ___ History of parasites (0=no; 1=yes)

124 ___ Less than one bowel movement a day

125 ___ Stools have corners or edges are flat or          ribbon shaped

126 ___ Stools are not well formed (loose)

127 ___ Irritable bowel or mucus colitis

128 ___ Blood in stool

129 ___ Mucus in stool

130 ___ Excessive foul smelling lower bowel gas

131 ___ Bad breath or strong body odour

132 ___ Painful to press along outer sides of thighs

133 ___ Cramping in lower abdominal region

Section 5

135 ___ History of Carpal Tunnel Syndrome (0=no;

1=yes)

136 ___ History of lower right abdominal pain (0=no

1=yes)

137 ___ History of stress fractures

138 ___ Bone loss (reduced bone density on scan)

139 ___ Are you shorter than you used to be (0=no

1=yes)

140 ___ Calf, foot or toe cramps at rest

141 ___ Cold sores, fever blisters or herpes lesions

142 ___ frequent fevers

143 ___ frequent rashes and/ or hives

144 ___ have you ever had a herniated disc (0=no

1=yes)

145 ___ Excessively flexible joints (double jointed)

146 ___ joints pop or click

147 ___ Pain or swelling in joints

148 ___ bursitis or tendonitis

149 ___ History of bone spurs (0=no; 1=yes)

150 ___ Morning stiffness

151 ___ Vomiting or nausea

152 ___ Crave chocolate

153 ___ feet have a strong odour

154 ___ Tendency to anaemia

155 ___ whites of eyes (sclera) blue tinted

156 ___ Hoarseness

157 ___ Difficulty swallowing

158 ___ Lump in throat

159 ___ dry mouth, eyes and/ or nose

160 ___ Gag easily

161 ___ white spots on fingernails

162 ___ Cuts heal slowly and / or scar easily

Section 6

164 ___ Aspirin is an effective pain reliever (0=no,

1 = yes)

165 ___ Crave fatty or greasy foods

166 ___ Low or reduced fat diet (past or present)

167 ___ Tension headaches at base of skull

168 ___ Headaches when out in the hot sun

169 ___ Sunburn easily or suffer sun poisoning

170 ___ Muscles easily fatigued

Section 7

172 ___ Awaken a few hours after falling asleep,

Hard to get back to sleep

173 ___ Crave sweets

174 ___ Eat desserts or sugary snacks

175 ___ binge or uncontrollable eating

176 ___ Excessive appetite

177 ___ Crave coffee or sugar in the afternoon

178 ___ sleepy in afternoon

179 ___ Fatigue that is relieved by eating

180 ___ Head ache if meals are skipped or delayed

181 ___ Irritable before meals

182 ___ Shaky if meals delayed

183 ___ family members with diabetes (0=none, 1=

2 or less; 2 = between 2 & 4; 3 = More

than 4)

184 ___ frequent thirst

 

Section 8

186 ___ Muscles become easily fatigued

187 ___ feel worse, sore after moderate exercise

188 ___ Vulnerable to insect bites

189 ___ Loss of muscle tone, heaviness in arms/legs

190 ___Enlarged heart or heart failure

191 ___ Pulse slow / below 65 bpm (0=no, 1=yes)

192 ___ Ringing in ears / Tinnitus

193 ___ Numbness, tingling or itching in extremities

194 ___ Depressed

195 ___ Fear of impending doom

196 ___ Worrier, apprehensive, anxious

197 ___ Nervous or agitated

198 ___ feelings of insecurity

199 ___ Heart races

200 ___ Can hear heart beat on pillow at night

201 ___ Whole body or limb jerk as falling asleep

202 ___ Night sweats

203 ___ restless leg syndrome

204 ___ Cheilosis (cracks at corner of mouth)

205 ___ fragile skin easily chaffed, as in shaving

206 ___ Polyps or warts

207 ___ MSG sensitivity

208 ___ Wake up without remembering dreams

209 ___ Take birth control pills

210 ___ Small bumps on back of upper arms

211 ___ Strong light at night irritates arms

212 ___ Nose bleeds and/ or tend to bruise easily

213 ___ Bleeding gums especially when brushing

Section 9

214 ___ Tend to be a ‘night person’

215 ___ Difficulty falling asleep

216 ___ Slow starter in the morning

217 ___ Keyed up, trouble calming down

218 ___ High Blood Pressure (normal 120/80)

219 ___ Headache after exercising

220 ___ Feeling wired or jittery if drinking coffee

221 ___ Clench or grind teeth

222 ___ Calm on the outside, troubled inside

223 ___ Chronic lower back pain, worse with fatigue

224 ___ Become dizzy when standing up suddenly

225 ___Difficulty maintaining manipulative correction

226 ___ Pain after manipulation correction

227 ___ Arthritic tendencies

228 ___ Crave salty food

229 ___ Salt foods before tasting

230 ___ Perspire easily

231 ___ Chronic fatigue or get drowsy often

232 ___ Afternoon yawning

233 ___ Afternoon headache

234 ___ Asthma, wheezing or difficulty breathing

235 ___ Pain on medial or inner side of knee

236 ___ Tendency to sprain ankles or shin splints

237 ___ Tendency to need to wear sunglasses

238 ___Allergies and/ or hives

Section 10

240 ___ Over 6’6” tall (mature height)

241 ___ Sexual development before aged 10 (0=no

1 = yes)

242 ___ Increased libido

243 ___ Splitting type headache

244 ___ Memory failing

245 ___ ability to tolerate sugar

246 ___ under 4’6” (mature height)

247 ___ Decreased libido

248 ___ Abnormal thirst

249 ___ Weight gain around hips or waist

250 ___ Menstrual disorders

251 ___ Sexual development after aged 13

Section 11

253 ___ Allergic to iodine

254 ___ difficulty gaining weight , even with large

appetite

255 ___ Nervous, emotional, can’t work under                         pressure

256 ___ Inward trembling

257 ___ Flush easily

258 ___ Fast pulse at rest

259 ___ Intolerance to high temperatures

260 ___ Difficulty losing weight

261 ___ Mentally sluggish, reduced initiative

262 ___ Easily fatigued, sleepy during the day

263 ___ Sensitive to cold, poor circulation (cold           hands and feet

264 ___ Constipation, chronic

265 ___ Excessive hair loss and/ or coarse hair

266 ___ Morning headaches, wear off during the day

267 ___ Loss of lateral 1/3 of eyebrow

Section 12 – Men only

269 ___ Prostate problems

270 ___ Urination difficult or dribbling

271 ___ Difficult to start and stop urine stream

272 ___ Pain or burning with urination

273 ___ Waking to urinate at night

274 ___ interruption of stream during urination

275 ___ Pain on inside of leg or heels

276 ___ Feeling of incomplete bowel evacuation

Section 13 – Women only

278 ___ Depression during periods

279 ___ Mood swings associated with periods (PMS)

280 ___ Crave chocolate around periods

281 ___ Breast tenderness associated with cycle

282 ___ Excessive menstrual flow

283 ___ Scanty blood flow

284 ___ Occasional skipped periods

285 ___ Variations in menstrual cycle

286 ___ Endometriosis

287 ___ Uterine fibroids

288 ___ Breast fibroids, benign masses

289 ___ Painful intercourse (dyspareunia)

290 ___ Vaginal discharge

291 ___ Vaginal dryness

292 ___ Vaginal itchiness

293 ___Gain weight around hips, thighs and buttocks

294 ___ Excess facial or body hair

295 ___ Hot flashes

296 ___ Night sweats (menopausal females)

297 ___ Thinning skin

__________________________________________

Section 14  

298 ___ Aware of heavy and/ or irregular breathing

299 ___ Discomfort at high altitudes

300 ___ ‘Air hunger’ and/ or yawn frequently

301 ___ compelled to open window in a closed room

302 ___ Shortness of breath with moderate exercise

303 ___ Ankles swell, especially at night

304 ___ Cough at night

305 ___ Blush or face turns red for no reason

306 ___ Dull pain or tightness in chest and/or             radiate into right arm

Section 15

308 ___ Pain in mid back region

309 ___ Dark circles under eyes and/ or puffy

310 ___ History of kidney stones 0= no, 1 = yes

311 ___ Cloudy, bloody or darkened urine

Section 16

313 ___ Runny or drippy nose

314 ___ catch colds at the beginning of winter

315 ___ Mucus producing cough

316 ___ Frequent infections (ear, sinus, lung,                          bladder, kidney etc)

317 ___ Frequent colds or flu

318 ___ Never get sick (1 = not in last 2 years; 2 =    not in the last 4 years; 3 = not in last 7           years)

319 ___ Acne (adult)

320 ___ Itchy skin/ dermatitis

321 ___ Cysts, boils, rashes

Children:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Any other information you feel is relevant.(e.g. memorable events which may have resulted in physical, mental or emotional traumas; drastic dietary changes)  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________