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Health Questionnaire

Please fill out the following health questionnaire before your consultation appointment.

Thyroid / Parathyroid

Do you have cold hands and feet?
Do you often get muscle spasms?
Are you suffering from depression?
Do you have scoliosis?
Do you have brittle finger nails?
Do you often have headaches or migraines?
Do you have Hashimotos?
Are you bruising easily?


Are you getting bloated regularly?
Do you see undigsted food matter in your stool?
Do you have acid reflux?
Are you very thin and have problems gaining weight?
Do you often have diarrhea?

Adrenal Glands

Do you have M.S., Parkinsons or Palsy?
Do you have jittering muscles or nervous legs?
Do you have problems with deep breathing?
Do you have anxiety attacks or are you overly fearful?
Do you have hypoglycemia (low blood sugar?
Do you have chronic fatigue?

Females Only

Do you have irregular cycles?
Are you on birth control pills?
Do you have or have you had fibroids?
Do you have heavy bleeding during your menstruation?
Do you have or have you had ovarian cysts?
Do you have an excessive sex drive?

Males Only

Do you have prostatitis (frequent urination esp. at night)?
Do you have testicular hypetrophy (enlargement)?
Do you have errection problems?
Do you have prostate cancer?
Do you have an excessive sex drive?
Do you have premature ejaculation?

Gastro - Intestinal Tract

Do you have gas problems?
Are you constipated?
Do you have gastritis?
Do you have diarrhea?
Do you have inflammation in the GI tract?

Liver / Gallbladder / Blood

Do you have problems with the digestion of fats?
Do you or did you ever have hepatitis?
Do you get pain in your mid back?
Do you have jaundice (yellowing of the skin)?

Heart & Circulation

Did you ever have a heart attack?
Do you get chest pain?
Do you have heart arrhythmia
Do you have a heart murmur?
Do you eve feel pressure on your chest?


Do you have eczema?
Do you have dry skin?
Do you have skin rashes?
Is your skin overly oily?
Do you have psoriasis?

Lymphatic System

Are you excessively loosing hair?
Have you ever had lymph nodes removed?
Do you have fibromyalgia?
Do you have swollen lymph nodes?
Are you getting grey hair?
Do you have problems with your sinuses?
Do you still have your tonsils?

Thanks for submitting!

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