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CONFIDENTIAL HEALTH QUESTIONNAIRE

This questionnaire takes about 20 minutes to complete.
All fields marked with an asterisk (*) are required.
    • Date Format: MM slash DD slash YYYY
    • MAIN PRESENTING SYMPTOMS
    • Click on the + button to create a new row
    • SUPPLEMENTS/MEDICATION
    • NAME OF PRODUCTBRAND NAMEDOSE (AMOUNT/TIME OF DAY)REASON FOR TAKINGDATE STARTED 
    • Click on the + button to create a new row
    • TYPICAL DAILY DIET
    • GENERAL FOOD CONSUMPTION
    • PROTEIN
    • PER DAY / WEEK / MONTH
    • CARBOHYDRATES
    • PER DAY / WEEK / MONTH
    • DRINKS
    • PER DAY / WEEK / MONTH
    • SMOKE & DRUGS
    • PER DAY / WEEK / MONTH
    • IgE and IgG Allergens
    • IgE: Allergy
    • IgG: Food sensitivity
    • STOOL AND URINE
    • Bristol Stool Chart

      Type 1

      Separate hard lumps, like nuts (hard to pass)

      Type 2

      Sausage-shaped but lumpy

      Type 3

      Like a Sausage but with cracks on its surface

      Type 4

      Like a Sausage or snake, smooth and soft

      Type 5

      Soft blobs with clear-cut edges (passed easily)

      Type 6

      Fluffy pieces with ragged edges, a mushy stool

      Type 7

      Watery, no solid pieces entirely liquid.

    • Digestion
    • Respiratory and Immune
    • Mind and Mental Health
    • Energy & Endocrine
    • Sleep and Nervous
    • Heart and Circulation
    • Skin, Nails and Hair
    • Musclo-skeletal - indicate where on diagram
    • Where?How Often? 
      Click on the + button to create a new row
    • Eyes
    • Ears
    • Exercise
    • Hormonal health - Female
    • If you are female and menstruating please describe your period:

    • Please tick any symptom you have experienced in the last few months

    • If you are female: Please tick any that apply

    • Hormonal health - Male
    • If you are male: Please tick any that apply

    • Other Factors
    • History
    • Please tick any relevant conditions for you and/or immediate family i.e. Brother, Sister, Mother, Father, Grandparents

    • Other Stressors
    • Are there any factors that you believe may have contributed to the change in your health?

    • Date Format: MM slash DD slash YYYY