Health Check Form

GENETIC / FAMILY Medical History (List the health issues each family member had, including Grand Parents both sides)

Personal Medical History

Injuries and Operations

Chemical Non-Prescription Medications / Quote Times and Dosages. Reason for taking?

Chemical Prescription Medications / Quote Times and Dosages. Reason for taking?

Natural Prescription Supplements / Quote Times and Dosages. Reason for taking?

Have you done or are you currently in treatment

Intake of Stimulants or Depressants

Intake of Stimulants or Depressants, Opiates (Drug derived from opium, psychoactive compounds such as morphine, codeine, thebaine), Hallucinogenic (Psychedelics, dissociative, deliriant), Benzodiazepine These are sedatives, hypnotics (sleep inducing), anxiolytic (anti-anxiety) anticonvulsants and muscle relaxants. (Psychoactive drugs such as chlordiazepoxide (Librium) or Diazepam (Valium)), Cannabinoids Most notable is tetrahydrocannabinol (THC), Solvents (Distinct chemical liquid, solid or gas), Amphetamines (Stimulants, empathogens, hallucinogens), Alcohol , Nicotine. Others

If any of the above, describe and when last taken?

Tick the boxes if yes

Myocardial Infarction (Heart Attack, tissue death of the heart muscle)

Angina (Chest Pain)

Heart Surgery

Multiple Sclerosis (Condition where the insulating covers of nerve cells in the brain and spinal cord are damaged)

Cancer (Abnormal cell degeneration)

Diabetes Type 1 ( Pancreas fails to produce enough insulin)

Diabetes Type 2 (The cells of the body do not respond properly to the insulin produced, Insulin Resistance)

Ridged Fingernails

Hyperthyroidism (Over Active Thyroid)

Hypothyroidism (Under Active Thyroid)

Tired All The Time

Hair Loss

Cold Extrimities

Overweight

Gall Stones

Kidney Stones

Gall Bladder Problems

Liver Problems

Kidney Problems

Addictions

Alcoholism

Mental Health Problems

Nervous Breakdown

Constipation/Diarrhea

Hepatitis (Inflammatory Condition of the Liver commonly caused by a viral infection))

Diverticulitis, Colitis (Active chronic inflammation of the sigmoid colon affected by luminal mucosal inflammation)

Parkinson's (neurodegenerative brain disorder)

Aids/HIV

High Blood Pressure

Low Blood Pressure

Swollen Lymph nodes

Irregular Menstruation Cycles

Water Retention

Hearing Problems

Digestion Problems

Eye Problems

Ulcers

If you answered yes to any of the above questions, please explain:

Part 1 / Tick the boxes if yes

I get cold hands and feet

it is easy to put on weight and hard to lose it

My fingernails are ridged

My fingernails are brittle

My fingernails are weak

I have varicose or spider veins

I have, or had hemorrhoids

I have, or had prolapsed organs

I get cramping in my muscles

My bladder is weak

My bladder is strong

I have irregular heartbeat

I have Mitral Valve Proplapse (Heart Murmer)

I get headaches or migraines

I had an hernia

I had aneurysm

I have osteoporosis

I have scoliosis

I get irritable easy

I have low energy levels

I suffer from symptoms of depression

I scored low on my bone density tests

My tests come back showing low calcium levels

I have, or had a goiter

I have spine deterioration

I have spine herniated disks

I have bone spurs

I have been diagnosed with Hashimoto or Reidel disease

Has a family member been diagnosed with Hashimoto or Reidel disease?

I sweat excessively

I sweat Medium

I sweat low

My legs get tired or cramps after a walk

I bruise easily (Parathyroid)

Part 2 Tick the boxes if yes

I get gas after I eat

I feel my foods just sitting in my stomach

I have acid reflux

I see undigested foods in my stool

I am thin and have a hard time putting on weight

My foods pass right through (Diarrhea)

I have moles on my body (Adrenal and Pancreatic weakness)

Medulla (Adrenal) Part 3 Tick the boxes if yes?

I am overweight.

I have M.S. Multiple Sclerosis, disorder in which insulating covers of nerve cells in the brain and spinal chord gets damaged.

I have Parkinson. Progressive disorder of the nervous system that affects movement.

I have Palsy. Affect, with paralysis and involuntary tremors.

I have anxiety attacks or feel overly anxious.

I feel excessive shyness or inferior to others.

I have tremors.

I have Nervous legs. RIS restless legs syndrome is a nervous system disorder that causes an overwhelming, irresistible urge to move the legs.

I have high Blood Pressure.

I have high Low Pressure.

I have Hypoglycemia low blood sugar, level of glucose in your blood drops below normal.

I have Type I Diabetes.

I have Type II Diabetes.

I have tinnitus. Ringing in the ears.

I have S.O.B. Shortness of breath or is it hard to take a deep breath.

I have heart Arrhythmias.

I have a hard time sleeping or insomnia (Pineal).

I have Chronic Fatigue Syndrome.

I have been diagnosed with Addison's Disease. Adrenal glands disorder, insufficient production of cortisol and aldosterone.

I have been diagnosed with Congenital Adrenal Hyperplasia. Genetic disorder, deficiency in cortisol and aldosterone hormones and an over production of the hormone androgen.

Cortex (Adrenal) Part 3b Tick the boxes if yes?

I have elevated blood cholesterol levels.

I have low steroids or cortisol levels. Cortisol helps the body use sugar, and fat for energy, helps the body manage stress. Steroids are secreted by steroid glands, adrenal cortex, testes and ovaries and are all derived from cholesterol.

I have inflammatory issues. Inflammations aim at removing harmful stimuli, damaged cells, irritants or pathogens to begin the healing process.

Do you have any 'itis's (inflammatory conditions) Which: (arthritis, bursitis, rheumatoid arthritis, enteritis, phlebitis, neuritis, etc...)

Part 4a Tick the boxes if yes?

I am menstruating Irregular. (Pituitary)

I get excessive bleeding during menstruation.

I have or had ovarian cysts.

I have or had fibroids. Abnormal growths.

I have or had endometriosis. Disorder in which the tissue that lines the inside of the uterus, grows outside your uterus.

I have or had A typical cells. Abnormal appearing cells caused by aging, inflammation and infection.

I have or had fibrocystic breasts.

I get sore breasts, especially during menstruation.

I have a low sex drive.

I have or had an excessive sex drive.

I had a miscarriage.

I had difficulty conceiving children.

Had you have a hysterectomy? Surgical tissue removal operation on the uterus. Date? Was it partial or complete?

Did they take any other organs out at the same time? (i.e.: gallbladder? Any other organs?

Have you had a D&C? (Removal of abnormal tissue from the inner lining of your uterus?) If yes, Date?

Have you been on birth control pills? For how long?

Are you currently pregnant? For how long?

Are you currently breastfeeding? For how long?

Have you experienced a miscarriage or termination?

Part 4b Tick the boxes if yes?

I have testicular hypertrophy. Increase in volume.

I have a low sex drive.

I have an excessive sex drive.

I have erection problems.

I have premature ejaculation.

Do you have prostatitis (swelling and inflammation of the prostate gland)? (Frequent urination, especially at night? If yes, how often do you urinate?

Do you have prostate cancer? What are you PSA counts?

Part 5 Tick the boxes if yes?

I have gastritis. Inflamed lining of the stomach after it has been damaged or eroded.

I have enteritis. Inflammation of the small Intestine, usually accompanied by diarrhoea.

My tongue is coated white. Especially in the morning.

My tongue is coated green. Especially in the morning.

My tongue is coated brown. Especially in the morning.

I have gastroparesis. Condition in which the stomach can't empty food properly, food passes more slowly than usual.

I have Hiatus Hernia. Occurs when the upper part of your stomach pushes up through your diagram into the chest area.

I have Colitis. Inflammation of the inner lining of the colon.

I have Diverticulitus. Painful condition developed by inflamed or infected pouches 9diverticula) in the wall of the colon.

I have Diarrhea.

I have Constipation.

I have or had stomach or intestinal ulcers.

I have Chrons's disease. Chronic inflammatory disorder in the intestines, especially the colon and ileum, associated with ulcers and fistulae.

I have "gas"problems.

Do you have or had you had any type of Gastro Intestinal Cancers? (stomach, colon, rectal, Etc...)

Do you have other Gastro Intestinal Problems?

How are your bowel movements like? 0,1,2,3 or more times a day. Dhiarea, you do not go every day? Describe.

Part 6 Tick the boxes if yes?

I have a problem digesting fats.

Fats or diary products cause bloating and / or pain in the stomach area.

My stools white or very light brown in color.

I get pain in the middle of your back. Especially after eating.

I get pain behind the right lower rib area.

I have "liver" or brown spots on my skin. (not freckles).

I am jaundiced. Yellowing of the skin.

I have skin pigmentation changes.

I am or have been anemic. Deficiency in healthy red blood cells. Lack of iron, iron-deficiency anemia.

I have or had hepatitis A. Form of viral hepatitis transmitted in food, causing fever and jaundice.

I have or had hepatitis B. Form of viral hepatitis spread through infected blood or body secretions.

I have or had hepatitis C. Blood borne virus causing both acute and chronic infection.

I have or had others. Hepatitis D,E & G.

Part 7 Tick the boxes if yes?

I get chest pains or angina.

I had a heart Attack (myocardial Infarction).

I had an open heart surgery.

I have a heart murmur or Mitral valve Prolapse.

I feel pressure on my chest.

I had high blood Pressure (Kidneys).

I have a pacemaker.

I have stints.

Do you have heart arrhythmia's? What Kind, to slow, to fast, irregular?

Do you get prickly pains, anywhere? especially in the heart area? Where?

Part 8 Tick the boxes if yes?

I get or had skin rashes.

I get skin blemishes.

I have eczema or dermatitis (Inflammation of the skin).

I have psoriasis (Raised red plaques covered with white scales).

My skin is dry.

My skin is excessively oily.

I get or have dandruff.

Do you itch anywhere? Where?

Do you have skin problems? If so, what type?

Part 9 Tick the boxes if yes?

I have hair loss, or I am bald or getting bald.

I had lymph nodes removed.

I have or had a goiter (Inflammation of the thyroid).

I have grey hair.

I have a hard time remembering things.

I get colds or flu like symptoms.

I have fibromyalgia (characterized by widespread musculosketal pain, accompanied by fatigue, sleep, memory and mood issues) or scleroderma (hardening of connective tissue).

I have sinus problems.

I have or get sore throats.

I have swollen lymph nodes.

I have a low platelet count.

My immune system is weak or sluggish.

I get boil , pimples, or cysts, etc..

I have or had abscesses.

I have or had toxemia (Blood poisening by toxins from a local bacterial infection).

Do have or had cellulitus (Potentially serious bacterial skin infection, swollen, hot, tender skin area that can easily spread to other parts of the body).

I Have or had gout (Form of inflammatory arthritis characterized by current attacks of red, tender, hot and swollen joint).

I get blurred vision.

I have much in my eyes when I wake up in the morning.

I snore.

I have sleep apnea (One or more pauses in breathing or shallow breaths while you sleep).

I exercise.

I exercise a lot.

Do you have or have you had tumors? If so, where? Fatty? Benign? Malignant?

Have you had appendicitis (Inflammation) or an appendectomy (Surgical removal)? when?

Have you had your tonsils (collections of lymphoid tissue) out? What age?

Part 10 Tick the boxes if yes?

I have or had urinary tract infections (UTI's).

I have or had burning upon urination.

I have problems holding my bladder. (parathyroid)

I have or had kidney stones.

I have bags under my eyes (esp.in the morning).

My urine flow is restricted.

I get cramping or pain on either side of my mid-to-lower back.

I have or had nephritis (Inflammation of the kidneys, may involve the glomeruli, tubules, or interstitial tissue surrounding the glomeruli and tubules).

I have lower back weakness.

I have or had sciatica (Symptoms of leg pain and possible tingling, numbness, or weakness originating in the lower back traveling through the buttock radiating down the sciatic nerve in the back of each leg).

I have or had cystitis (Inflammation of the bladder, UTI).

Part 11 Tick the boxes if yes?

I have (or have had) bronchitis (Inflammation of the lining of my bronchial tubes, which carry air to and from the lungs).

I have (or have had) emphysema (Lung condition that causes shortness of breath, the air sacs in the lungs (alveoli) are damaged). Caused by smoking or other toxic fumes.

I have (or have had) asthma (Constant inflammation of airways).

I have (or have had) C.O.P.D (Chronic Obstructive Pulmonary Disease).

I get pain when I breathe.

I get pain when I take a deep breath. (Adrenals)

It is difficult to take a deep breath.

I had or have lung cancer.

I have a collapsed lung.

I am a smoker.

I am or have been a second hand smoker.

I have or had pneunomia (Inflammatory condition of the lung affecting primalary the microscopic air sacs known as alveoli, symptoms may include, dry cough, chest pain, fever and trouble breathing)?

I have worked around toxic chemicals, in coal mines or around asbestos.

I cough a lot.

I get mucus when I cough.

The color of my mucus is clear.

The color of my mucus is brown.

The color of my mucus is black.

Are you on inhalers or nebulizers? How often and what type?

Your oxygen saturation level is? If you have lung disease or other types of medical conditions, fewer of your red blood cells may be carrying their usual load of oxygen, 95%-100% of red blood cells passing through the lungs should be saturated.

Are you a smoker? How often? How many packs or cigarettes a day?

Are you affected by second hand smoke or environmental smoke and exhaust fumes from cars, ferry's, etc...

Part 12 Tick the boxes if yes?

I have been vaccinated.

I had shots for traveling to foreign countries.

I had flu shots.

I have mercury amalgams.

I find it difficult to take deep breaths.

Have you had radiation? Chemotherapy? If so, how many treatments?

Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?

Do you have any allergies? (Food, chemicals, etc...)

What are your major health complaints and concerns? Are there any not covered in this questionnaire?

Describe your professional life, do you like it, love it, or are in need of a change?

Health Check Form

Health Check Form Questionnaire

Confidential Information

Health History

Important Health Questions

THYROID/PARATHYROID (GLANDULAR SYSTEM)

PANCREAS

ADRENAL GLANDS (GLANDULAR SYSTEM)

FEMALES ONLY

MALES ONLY

GASTRO INTESTINAL TRACT

LIVER / GALLBLADDER / BLOOD

HEART AND CIRCULATION

SKIN

LYMPHATIC SYSTEM

KIDNEY AND BLADDER

LUNGS

ENVIRONMENTAL TOXINS

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