General Health Questionnaire

Use this questionnaire to gauge your general health. Please complete prior to your first appointment and let us know the results.

Instructions:

Place a check in the box if the answer to the question is “yes” and leave the box empty if the answer is “no”.

1.    Fill in your score where indicated.

2.    Save this questionnaire to compare future results from before and after 90 days of treatment

Overall Well-being

How well are you doing?

Consider your current symptoms and overall sense of well-being

□        Do you feel basically healthy?

□        Do you consider yourself to be happy?

Please list any negative symptoms you are currently experiencing.

Metabolic Function

Do you have chronic inflammation in your body?

If you answer “yes” to 3 or more questions you may have chronic inflammation.

□        Do you elevated cholesterol or triglycerides?

□        Do you numbness or tingling in your arms or legs?

□        Do you feel basically healthy?

□        Do you eat meat, commercially baked sweets, fried foods, or use vegetable oil daily?

□        Do you consume fish less than 2 times per week?

□        Do you have high blood pressure, asthma, or colitis?

□        Do you smoke?

□        Do you have gingivitis, periodontal disease, or have not had regular dental cleanings and check-ups at least once per year?

What is your score? Add up the number of “yes” responses.

Do you have poor nutrition and digestion?

If you answer “yes” to 4 or more questions you may have poor nutrition and digestion.

□        Do you regularly include fast food in your diet three or more times per week?

□        Do you experience belching, fullness soon after eating, or frequent excess gas/bloating?

□        Do you experience heartburn or acid reflux two or more times per week?

□        Do you have any food allergies or intolerances?

□        Do you feel tired or lethargic after eating?

□        Do you commonly have bad breath or a bad taste in your mouth?

□        Do you use digestive aids such as laxatives, antacids, or acid-blocking drugs?

□        Do you often feel “older” than you think you should for your age?

□        Do your skin look yellowish, gray, puffy, wrinkled, or aged?

What is your score? Add up the number of “yes” responses.

Are you pre-diabetic or at risk?

If you answer “yes” to 3 or more questions you might have abnormal blood sugar, insulin resistance, or a compromised metabolism.

□        Do your waistline extend beyond your hips or are you overweight?

□        Do you become tired or light-headed and do you feel the need to eat again in just two or three hours after your last meal?

□        Do you eat exercise less than three times per week?

□        Do you eat two or more servings of bread, pasta, candy, colas, or fruit juice per day?

□        Do you eat fewer than five servings of fresh, raw vegetables and fruits per day?

□        Do you Do you have high blood pressure or elevated blood fats?

What is your score? Add up the number of “yes” responses.

Do you have low energy levels?

If you answer “yes” to 3 or more questions you might have impaired cellular/mitochondrial function.

□        Do you frequently find yourself tired for no reason?

□        Do you have stiff and sore muscles unrelated to exercise?

□        Do you have poor stamina, shortness of breath, or feel exhausted while exercising?

□        Do you exercise less than two hours per week?

□        Do you look and feel older than your true age?

□        Have you ever been exposed to toxic chemicals or heavy metals?

□        Have you ever been diagnosed with iron deficiency or do you have a heavy menses?

What is your score? Add up the number of “yes” responses.

Toxicity and Exposure

Do you have a toxic overload?

If you answer “yes” to 4 or more questions your body may need help in efforts to detoxify.

□        Do you become physically ill when exposed to strong smells (perfume, auto-exhaust, cigarette smoke, etc.)?

□        Do you use chemical cleaners or solvents at home, work, or in your hobbies?

□        Do you live in a house/condo/apartment or work in an office less than 5 years old?

□        Do you have amalgam dental fillings?

□        Are you prone to side effects from medications or supplements?

□        Have you become more sensitive or less tolerant to the effects of alcohol or caffeine?

□        Do you smoke?

□        Do you have fewer than two bowel movements per day?

□        Do you or have you ever had breast implants?

□        Do you have pets that are furred or feathered?

□        Do you wake up often during the night to urinate?

What is your score? Add up the number of “yes” responses.

Is your home and/or work environment toxic?

If you answer “yes” to 4 or more questions your home or office needs a health makeover.

□        Do you have carpet in your home/office?

□        Are the floors vacuumed less than 3 times per week?

□        Has the filter HVAC air filter been changed in the past 30 days?

□        Do you routinely drink tap water?

□        Do you have left shoulder pain?

□        Do you wash clothing and bedding in unfiltered city water?

□        Have the interior rooms of your home/office been repainted recently?

□        Are there black spots or mold on the air vents or walls?

□        Have the air vents been cleaned in the past year?

□        Are chemical cleaners used in your home/office?

□        Are chemical fertilizers, insecticides, or pesticides in use?

What is your score? Add up the number of “yes” responses.

Immune Function

Is your immune system impaired?

If you answer “yes” to 4 or more questions your immune system may be compromised.

□        Do you catch colds or the flu easily?

□        Do colds, flu, or other infections tend to linger more than 5 days?

□        Do you have a chronic cough, scratchy throat, sinus congestion, or excess mucous making it necessary to clear your throat often?

□        Do you have seasonal allergies or known allergies to food, dust, animals, or mold?

□        Have you ever been diagnosed with an auto immune disease, such as rheumatoid arthritis, chronic fatigue, lupus, celiac disease, Sjogrens, or fibromyalgia?

□        Do you have dark circles under your eyes?

□        Do you have difficulty seeing at night?

□        Do you have white spots on your fingernails?

□        Have you recently received any vaccinations?

□        Have you served in the military in the last 15 – 20 years?

What is your score? Add up the number of “yes” responses.

Has your liver been impaired by toxic emotions?

If you answer “yes” to 5 or more questions your liver may be impaired and you need help in efforts to detoxify your thoughts and emotions.

□        Do you feel angry from time to time?

□        Do you find that you become agitated easily?

□        Do you have frequent mood swings?

□        Do you have difficulty staying in a good mood?

□        Do you run out of energy during the day?

□        Do you have brown spots or age spots on your skin?

□        Does your skin break out or become blemished?

□        Are your emotions often on a roller coaster?

□        Do you have to apologize for your bad moods to friends, family, co-workers, etc.?

□        Do you always find something wrong in your life?

□        Have you ever been physically or sexually abused?

□        If you are upset, is it best not to talk to you about what is going on?

□        Do you get annoyed by the “fake cheeriness” of others?

□        Do these questions irritate you?

What is your score? Add up the number of “yes” responses.

Are your kidneys and urinary system functioning properly?

If you answer “yes” to 5 or more questions your kidneys may be overworked.

□        Do you have pain in your muscles and joints?

□        Have you had kidney or bladder infections in the past year?

□        Have you experienced ankle pain and swelling in the past year?

□        Do you have left shoulder pain?

□        Do your fingernails chip or break easily?

□        Do you have puffiness, bags, or dark circles under your eyes?

□        Do you have thinning hair?

□        Do you have frequent scalp or skin irritations?

□        Do you have painful menstrual cycles?

□        Do you wake up often during the night to urinate?

□        Do you feel exhausted in the morning even after sleeping more than 8 hours?

□        Have you ever been diagnosed with thyroid problems?       

What is your score? Add up the number of “yes” responses.

Hormone Balance

Do you have adrenal dysregulation?

If you answer “yes” to 3 or more questions your adrenal system may be suffering or exhausted.

□        Do you frequently feel stressed out?

□        Do you have difficulty falling asleep or staying asleep through the night?

□        Do sudden noises make you jump?

□        Do you become dizzy or light-headed when standing up too quickly?

□        Do you crave salt or sugar?

□        Do you drink coffee?

□        Have you taken diet pills in the past 3 years?

□        Do you drink highly caffeinated beverages such as soft drinks or energy drinks?

□        Do you exercise less than 3 times per week?

What is your score? Add up the number of “yes” responses.

Do you have thyroid dysregulation?

If you answer “yes” to 4 or more questions your thyroid may be imbalanced.

□        Are you frequently cold?

□        Do you have trouble getting started in the morning?

□        Do you often feel depressed, particularly in the morning?

□        Are you unable to lose weight despite improving your diet and exercising more?

□        Do you have hair loss from your head, arms, or legs?

What is your score? Add up the number of “yes” responses.

Are your sex hormones reduced in production or quality?

If you answer “yes” to 2 or more questions your sex hormones may be reduced.

□        Are you flabby, or have you experienced a loss of muscle tone?

□        Do you suffer from low libido?

□        Do you frequently experience headaches or migraines?

□        Do you have PMS?

What is your score? Add up the number of “yes” responses.

FOR WOMEN – Is your body out of balance?

If you answer “yes” to 6 or more questions your sex hormones may be out of balance.

□        Are you very easily fatigued?

□        Do you suffer from PMS?

□        Do you have painful menses?

□        Do you frequently experience depression before or during your menstruation?

□        Is your menstrual cycle prolonged or excessive in terms of blood flow?

□        Are your breasts overly sensitive or painful before, during, or after menstruation?

□        Do you menstruate too frequently (more than once per month or sporadic flow)?

□        Do you produce a vaginal discharge?

□        Have you had a hysterectomy or had your ovaries removed?

□        Do you have menopausal hot flashes?

□        Is your menses irregular or absent altogether?

□        Do you have acne or other skin blemishes that worsen during menses?

□        Have you felt depressed for 3 months or longer?

□        Do you have hair growth on your face or body?

□        Do you have or desire sex less than 2 times per month?

What is your score? Add up the number of “yes” responses.

FOR MEN – Is your body out of balance?

If you answer “yes” to 6 or more questions your sex hormones may be out of balance.

□        Are you very easily fatigued?

□        Do you have premature ejaculation?

□        Is urination difficult or do you dribble (can’t stop completely)?

□        Have you experienced or are you experiencing prostate trouble?

□        Do you often wake up during the night to urinate?

□        Do you have pain inside of your legs or heals?

□        Do you have feelings of incomplete bowel evacuation or not emptying fully?

□        Do you have difficulty sleeping?

□        Do you avoid routine or even mild physical activity?

□        Do you run out of energy during the day?

□        Do you experience leg nervousness or twitching during the night?

□        Do you have difficulty falling asleep or maintaining sleep through the night?

□        Have you felt depressed for 3 months or longer?

□        Do you have or desire sex less than 2 times per month?

What is your score? Add up the number of “yes” responses.

Note – This General Health Questionnaire is not intended to diagnose, treat, cure, or prevent any disease. None of the statements herein have been evaluated by the FDA nor is any endorsement thereof implied or given.

We advise use of this Questionnaire simply as a starting point for consideration of any negative health symptoms you may be experiencing and potential preventative measurements or as resources for further discussion with your healthcare provider..