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I Appreciate You Taking The Time To
Fill Out My Custom Questionnaire 🙂
Answer all questions as honestly as possible, and I will review!
The Questionaire
Name
Name
First
First
Last
Last
Address
Phone
Email
Age
Weight
Body Size: XS, S, M, L, XL, XLL+
Live With:
Occupation:
Emergency Contact:
Emergency Contact:
How did you hear about Doctor Carol?
Why do you want to “coach” with me?
What is your major complaint when it comes to your health?
How many days did you miss work the past year?
Please list your current medication.
Please list your current supplements.
Describe any current or past recreational drugs:
Please list current and past health conditions:
Is there anything else in your medical history that you consider relevant?
What is your employment history?
Please list your past or present hobbies that could be the source or chemical exposure:
Please list all past surgeries:
Explain your sleep cycle: (plenty of sleep, little to no sleep, get up in the middle of the night)
What type of health equipment have you purchased?
Is there a particular diet that you follow?
What are the foods you stay away from?
What foods do you consume the most of?
How many servings of wine per week do you have?
Do you currently use tobacco?
Do you have a Smart Meter in your home?
Do you need to drink caffeine to get going?
Have you ever had any chemical exposure?
Have you ever lived near a golf course, freeway, or tensions wires? (please explain)
Can you think of any other toxic exposures that you may know of?
Do you crave sugars or sweets?
Have you ever been diagnosed with diabetes?
Have you ever been diagnosed with bipolar disorder?
Is your sexual drive underactive?
Do you have rapid mood swings?
Are you in a constant state of anxiety or fear?
Do you have jock itch?
Do you use any prescriptions to improve sexual function?
Are you in or did you go through perimenopause or menopause?
Do you have irregular period?
Do you have a history of miscarriages?
Have you ever taken estrogen, progesterone, testosterone, DHEA, or hGH?
Do you have a history of using anti-acids or anything that blocks acid?
Do you currently use birth control?
Have you been on antibiotics in the past year?
Were you caesarian delivered? (C-Section)
Were you breastfed? (If so, how long)
Have you gotten food poisoning before?
Do you have a history of jock itch or vaginal yeast infection?
Do you have a history of athlete’s foot or foot fungus?
Do you experience excessive belching, burping and/or bloating?
never or rarely
twice a week or less
three to six times a week
daily
Do suffer from gas immediately following a meal?
never or rarely
twice a week or less
three to six times a week
Daily
Do you ever have difficult bowel movements?
never or rarely
twice a week or less
three to six times a week
daily
Do you have an uncomfortable sense of fullness during meals ?
yes
no
Do you have a history of anemia?
yes
no
Are you a vegetarian who doesn’t eggs or dairy products?
yes
no
Do you get sores in the corner of your mouth?
never or rarely
twice a week or less
three to six times a week
daily
If you examine your tongue?
Is it deep pink
Is it whitish pink
Is it solid white
Is it greyish white
Is it furry looking
Do you have spoon-shaped nails ?
yes
no
Do you suffer from a partial loss of taste or smell?
never or rarely
occasionally
frequently
Do you suffer from indigestion and fullness lasting 2 to 4 hours after eating?
never or rarely
twice a week or less
three to six times a week
daily
Do suffer from pain, tenderness and/or soreness on your left side under your rib cage?
never or rarely
twice a week or less
three to six times a week
daily
Do you ever have an excessive passing of gas?
never or rarely
twice a week or less
three to six times a week
Daily
Do you feel constantly bloated?
yes
no
Do specific foods or beverages aggravate your digestion?
yes
no
Do you experience abdominal cramps or stomach aches?
never or rarely
twice a week or less
three to six times a week
daily
Do you frequently experience nausea and/or vomitting?
never or rarely
twice a week or less
three to six times a week
daily
Do you have alternating constipation and diarrhea?
never or rarely
twice a week or less
three to six times a week
daily
Do you have undigested food in your stool?
never or rarely
twice a week or less
three to six times a week
daily
Do you have signs of mucus in your stool?
never or rarely
twice a week or less
three to six times a week
daily
Do you have difficulty gaining weight?
yes
no
Do you suffer stomach pains and/or burning, aching 1 to 4 hours after eating?
never or rarely
twice a week or less
three to six times a week
daily
Do you get heartburn from spicy foods when you are lying down or bending forward?
never or rarely
twice a week or less
three to six times a week
daily
Do you have difficulty or pain when swallowing?
never or rarely
twice a week or less
three to six times a week
daily
Do you experience relief from carbonated beverages, cream, milk or food ?
never or rarely
twice a week or less
three to six times a week
daily
Do you have black tarry-looking stools?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from lower abdominal pain, cramping and/or spasms?
never or rarely
twice a week or less
three to six times a week
daily
Do you find relief from lower abdominal pain by passing stools or gas?
never or rarely
twice a week or less
three to six times a week
daily
Do you experience more than three bowel movements within a day?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from painful, difficult, straining during bowel movements?
never or rarely
twice a week or less
three to six times a week
daily
Do you produce hard, dry or small stools?
never or rarely
twice a week or less
three to six times a week
daily
Do you feel that your bowels do not empty completely?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from anal itching?
never or rarely
twice a week or less
three to six times a week
daily
Do you regurgitate bitter fluid?
never or rarely
twice a week or less
three to six times a week
daily
Do you find that fatty foods cause indigestion?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from unexplained itchy skin which is worse at night?
never or rarely
twice a week or less
three to six times a week
daily
Does your stool color alternate between clay colored and normal brown?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from fatigue, weakness and/or exhaustion?
never or rarely
twice a week or less
three to six times a week
daily
Do you ever feel unable to concentrate, feel irritable and/or confused ?
never or rarely
twice a week or less
three to six times a week
daily
Do you suffer from swollen feet and/or legs?
never or rarely
twice a week or less
three to six times a week
daily
Do you find your skin is easily bruised?
yes
no
Do you suffer from dry, flaky skin and hair?
yes
no
Do you have a yellowish cast to your skin and around your eyes?
yes
no
Are the outer third of your eyebrows thin?
yes
no
Do you have dark urine and/or a diminished flow?
yes
no
Do you have swollen upper eyelids?
yes
no
Do you suffer from slow mental processes and forgetfulness?
yes
no
Do you suffer from slow heart beats?
yes
no
Do you have a lack of interest in sex?
yes
no
Do you suffer from premenstrual tension?
yes
no
Do you suffer from heavy menstrual bleeding?
yes
no
Do you suffer from infertility?
yes
no
Do you gain weight easily?
yes
no
Do you suffer from thinning hair on your scalp, face and genitals?
yes
no
Do you suffer from general weakness?
yes
no
Do you suffer from progressive, mild fatigue after exertion or stress?
yes
no
Do you suffer from depression?
yes
no
Do you suffer from blurred vision and/or dizziness when rising?
yes
no
Do you suffer from rapid mood swings?
yes
no
Do you feel irritable and/or nervous?
yes
no
Do you have dark circles under your eyes?
yes
no
Do you have blotchy skin which includes white patches?
yes
no
Do you suffer from spinal curvature?
yes
no
Have you suffered a recent loss of height?
yes
no
Do you suffer from unexplained bone fractures?
yes
no
Do you suffer from tooth loss and/or gum disease?
yes
no
Are there specific points on your body that feel sore when pressed?
yes
no
Do you suffer excessive looseness of joints?
yes
no
Do you suffer from numbing and tingling sensations?
yes
no
Are you double jointed?
yes
no
Do you feel fatigued and sluggish?
never or rarely
twice a week or less
three to six times a week
daily
Do you have difficult and/or infrequent bowel movements?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do your muscles feel weak, do they cramp and/or tremble?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from loss of appetite?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from an unsteady gait and abnormal walking movements?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you feel disinterested in food?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from indigestion?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you have a craving for salty foods?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from generalized bone tenderness and aching?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do your shins hurt during or after exercises?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from hearing loss, headaches, and/or ringing in the ears?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer joint pain and stiffness – especially in your spine, hips and/or knees?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from localized muscle stiffness, tension and/or pain?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from headaches?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you have difficulty sleeping?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from muscle weakness or loss?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you feel un-refreshed upon awakening?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do your muscles twitch or tremble, such as your eyelids, calf muscles, or your thumb?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you have an irresistible urge to move your legs?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer from joint stiffness and/or soreness?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do your legs move during your sleep?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Does your joint stiffness worsen with rest and improve with movement?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you have a limited range of motion?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you have difficulty standing up from a sitting position?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Do you suffer numbness, prickling and/or a tingling sensation in the neck, shoulder and/or arms?
Never or Rarely
Twice a week or less
Three to six times a week
Daily
Any Exposure? Radio Tower?
No Known Exposure
Current Exposure
Past Exposure
Any exposure? Landfill dump?
No Known Exposure
Current Exposure
Past Exposure
Exposure at Home or Work – water leaks ?
Yes
No
Exposure at Home or Work – visible mold ?
Yes
No
Exposure at Home or Work – damp basement ?
Yes
No
Exposure at Home or Work – carpets ?
Yes
No
Have you been exposed to secondary smoking ?
Yes
No
Do you smoke cigarettes / cigars / pipe ?
Yes
No
Have you come into contact (significantly) with pesticides, herbicides, chemicals, varnish, glue, paints, cleaning agents, mercury, lead ?
Yes
No
Do you have allergies?
Yes
No
Sometimes
Do you regularly consume artificial sweeteners ?
Yes
No
Are you subject to frequent airplane travel ?
Yes
No
Do you drink soda ?
Never or rarely
Three a week or less
Three to six times a week
Daily
Do you feel under stress ?
Never or rarely
Three a week or less
Three to six times a week
Daily
Do you regularly consume alcohol ?
Never or rarely
Three a week or less
Three to six times a week
Daily
Have you ever had food poisoning ?
Yes
No
Have you ever experienced a traumatic event ?
Yes
No
Dental work – Do you have amalgam fillings ?
Yes
No
Have you ever indulged in recreational drugs ?
Yes
No
Dental Work – Do you have any root canals ?
Yes
No
Will you list in the box below, any prescription and over-the-counter medications you are taking?
Will you list in the box below, any vitamins and supplements you are taking ?
If I have nothing for breakfast or perhaps just some coffee, it’s easier to control my eating for the rest of the day, than if I have breakfast that contains carbohydrates.
Yes
No
I’m a “bet you can’t eat just one” person and find it difficult to stop once I start snacking on sweets and starches.
Yes
No
I often feel very sluggish and/or hungry by mid-afternoon.
Yes
No
Cakes, cookies and other sweets make me feel better if I am feeling “down” or tired.
Yes
No
If I am trying to diet and lose some weight, it’s easier to skip meals and not eat for most of the day, than to try to eat small diet meals.
Yes
No
A meal including bread or potatoes or pasta or dessert has often left me feeling sleepy, tired,or “drugged”. A meal made up of only meat and salad does not have the same effect.
Yes
No
Sometimes I would classify myself as a “secret eater”.
Yes
No
Daily
A meal of only meat and vegetables does not satisfy me.
Yes
No
I prefer potatoes, bread, pasta and dessert to other foods and will often skip eating salads and vegetables for them.
Yes
No
I often crave a bedtime snack before going to sleep.
Yes
No
If I wake in the middle of the night, it’s easier to get back to sleep if I snack something.
Yes
No
When at a restaurant, I often eat too much bread before the meal is served.
Yes
No
Watching other people eat when I am not is annoying to me.
Yes
No
Number
If you are human, leave this field blank.
Submit
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