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Health Questionnaire
Health Questionnaire
Art of Detox
2023-02-15T14:22:52+00:00
Health Questionaire
A Self-Assessment
"
*
" indicates required fields
Step
1
of
15
- Personal Information
6%
Personal Information - 27/07/2024
To eat when you are sick, is to feed your sickness.
1.1 Name
*
First
Last
1.2 Gender
*
Male
Female
1.3 Email
*
1.4 Height (cm)
*
1.5 Weight (kg)
*
1.6 Date of Birth
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1.7 Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
1.8 Cell Phone
*
1.9 Phone
1.10 Skype
1.11 Are you taking any medications? Please list individually below with dosages.
Medications
Dosage
Add
Remove
Click the + sign to add more lines
1.12 Are you taking any Herbal Products or Supplements? Please list individually below:
Add
Remove
Click the + sign to add more lines
1.13 What does your current daily diet consist of?
*
Breakfast
Lunch
Dinner
Snack
1.13.1 What does your current diet consist of? Be honest!
1.14 What are your primary health concerns?
1.15 What do you hope to gain from this program?
Genetic / Family History
Please list all known health concerns for each family member. Leave blank if you aren't sure
1.16.1 Mother
1.16.2 Father
1.16.3 Maternal Grandmother
1.16.4 Maternal Grandfather
1.16.5 Paternal Grandmother
1.16.6 Paternal Grandfather
1.16.7 Sister/Brother
Sister / Brother
Health Concern
Add
Remove
Click the + sign to add more lines
1.17 Your Previous Surgical Procedures
Surgical Procedure
Year
Add
Remove
Please list all surgical procedures, minor or major, along with the year. Click the + sign to add more lines
Vitals Information
(If you are not sure of your vital sign readings, you may leave them blank)
2.1 Eye Color
2.2 Blood Pressure (Left)
2.3 Blood Pressure (Right)
2.4 Pulse
2.5 Respirations
2.6 Basal Temp. (Cº)
2.7 pH (Urine or Saliva)
2.8 How many bowel movements do you have per day?
2.9 How often do you move your bowels per week?
People assume that having thyroid disease means you're older and overweight, but in reality, thyroid disease strikes at all ages and affects all sizes.
3.1 Do you get cold hands and/or feet?
*
Yes
No
3.2 Do you feel cold often or have a hard time getting warm?
*
Yes
No
3.3 Are you cold, but burning inside?
*
Yes
No
3.4 Is it easy to put on weight and hard to lose it?
*
Yes
No
3.5 Do you have an irregular heartbeat?
*
Yes
No
3.6 Do you get headaches or migraines?
*
Yes
No
3.6.1. Please Elaborate
*
3.7 Do you become irritable easily?
*
Yes
No
3.8 Do you have low energy levels?
*
Yes
No
3.9 Do you have, or have ever had a goiter?
*
Yes
No
3.10 Have you been diagnosed with Hashimoto or Reidel disease?
*
Hashimoto
Reidel
No
3.11 Has a family member?
*
Yes
No
A Parathyroid Glandular is stronger and faster acting. Berries are good for the endocrine glands.
4.1 Are your fingernails:
*
Ridged
Brittle
Weak
Normal
4.2 Do you have varicose or spider veins?
*
Yes
No
4.3 Do you, or have you had:
*
Hemorrhoids
Prolapsed organs
No
4.4 Do you experience cramping in your muscles?
*
Yes
No
4.5 Is your bladder strong or weak?
*
Strong
Weak
4.7 Have you ever had a hernia?
*
Yes
No
4.8 Have you ever had an aneurysm?
*
Yes
No
4.9 Do you have osteoporosis and/or score low on your bone density tests?
*
Yes
No
4.10 Do you have scoliosis?
*
Yes
No
4.11 Do you suffer from symptoms of depression?
*
Yes
No
4.12 Do you suffer from any other mental illness?
*
Yes
No
4.12.1 Which?
*
4.13 Do your tests come back showing low Calcium levels?
*
Yes
No
Dont Know
4.14 Do you have spine deterioration, herniated discs, or bone spurs?
*
Yes
No
4.15 Do your legs get tired or cramp after you walk?
*
Yes
No
4.16 Do you bruise easily?
*
Yes
No
5.1 Do you get gas after you eat?
*
Yes
No
5.2 Do you feel your foods just sitting in your stomach?
*
Yes
No
5.3 Do you have Acid Relfux?
*
Yes
No
5.4 Do you see any undigested foods in your stools?
*
Yes
No
5.5 Are you thin and have a hard time putting on weight?
*
Yes
No
5.6 Do your food pass right through you (diarrhea)?
*
Yes
No
5.7 Do you have moles in ypur body? (Adrenal & Pancreatic weakness)
*
Yes
No
6.1 Are you overweight?
*
Yes
No
6.2 Do you have:
*
M.S.
Parkinson's
Palsy
N/A
6.3 Do you have anxiety attacks or feel overly anxious?
*
Yes
No
6.4 Do you feel excessive shyness or inferior to others?
*
Yes
No
6.5 Do you have tremors, nervous legs, etc?
*
Yes
No
6.6 Do you have High or Low Blood Pressure?
*
High
Low
6.6.1 Systolic (Upper BP number)
6.6.2 Diastolic (lower number)
6.7 Do you have Hypoglycemia (low blood sugar)?
*
Yes
No
6.8 Do you have Diabetes (high blood sugar)?
*
Yes
No
6.8.1 Diabetes TYPE
*
TYPE I
TYPE II
6.9 Do you have tinnitis (ringing in the ears)?
*
Yes
No
6.10 Do you have S.O.B. (shortness of breath) or its hard to take a breathe?
*
Yes
No
6.11 Do you have arrhythmias?
*
Yes
No
6.12 Do you have a hard time sleeping or insomnia?
*
Yes
No
6.13 Do you have Chronic Fatigue Syndrome?
*
Yes
No
6.14 Have you been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia?
*
Addison's Disease
Congenital Adrenal Hyperplasia
None
6.15 Do you have elevated blood cholesterol levels?
*
Yes
No
6.16 Do you have arthritis, bursitis, or any inflammatory issues?
*
Yes
No
6.16.1 Which?
*
6.17 Do you have low steroid or cortisol levels?
*
Yes
No
6.18 Have you been diagnosed with Autism?
*
Yes
No
6.19 Have you been diagnosed with ADD (attention deficit disorder) or ADHD (attention deficit hyperactivity disorder)?
*
Yes
No
7.1 Are your menstruation cycles irregular?
*
Yes
No
7.2 Do you have excessive bleeding during menstruation?
*
Yes
No
7.3 Do you have or have you had ovarian cysts?
*
Yes
No
7.3.1 When?
*
Year
7.4 Do you have or have you had endometriosis or A-typicall cells?
*
Yes
No
7.4.1 Which ones?
*
7.5 Do you have or have you had fibroids?
*
Yes
No
7.5.1 When?
*
7.6 Do you have or have you had fibrocystic breasts?
*
Yes
No
7.6.1 When?
*
7.7 Do you get sore breasts, especially during menstruation?
*
Yes
No
N/A
7.8 Do you have a low or excessive sex drive?
*
Low sex drive
Excessive sex drive
Average
7.9 Have you had a hysterectomy?
*
Yes
No
7.9.1 Year
*
7.9.2 Was it:
*
Partial
Complete
7.10 Did you take any other organs out at the same time? (i.e.:gallbladder)
*
Yes
No
7.11 What organs?
*
7.11.1 In what year?
*
7.12 Have you had a miscarriage?
*
Yes
No
7.12.1 Year
*
7.13 Have you had difficulty conceiving children?
*
Past
Present
No
7.14 Have you been on Birth Control Pills?
*
Yes
No
7.14.1 How long?
*
7.15 Are you currently pregnant?
*
Yes
No
8.1 Do you have gastritis or enteritis?
*
Yes
No
8.2 Is your tongue coated (white, yellow, green or brown), especially in the morning?
*
Yes
No
8.3 Do you have gastroparesis?
*
Yes
No
8.4 Do you have a Hiatus Hernia?
*
Yes
No
8.5 Do you have Colitis?
*
Yes
No
8.6 Do you have Diverticultis?
*
Yes
No
8.7 Do you get or have Diarrhea?
*
Yes
No
Normal
8.8 Do you get or have Constipation?
*
Yes
No
Normal
8.9 Do you ever had stomach or intestinal ulcers?
*
Yes
No
8.10 Do you or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal, etc.)
*
Yes
No
8.10.1 Please tells us more
*
8.11 Do you have Crohn's Disease?
*
Yes
No
8.12 Do you have "gas" problems?
*
Yes
No
9.1 Do you have a problem digesting fats?
*
Yes
No
9.2 Do fats or dairy foods cause bloating and/or pain in the stomach area?
*
Yes
No
9.3 Are your stools white, or very light brown in color?
*
Yes
No
9.4 Do you get pain in the middle of your back (especially after eating)?
*
Yes
No
9.5 Do you get pain behind the right, lower rib area?
*
Yes
No
9.6 Do you have "liver" or brown spots on your skin? (not freckles)
*
Yes
No
9.7 Are you jaundiced (yellowing of the skin) or eyes?
*
Yes
No
9.8 Do you have any skin pigmentation changes?
*
Yes
No
9.9 Are you or have you ever been anemic?
*
Yes
No
9.10 Do you have or ever had, Hepatitis?
*
Yes
No
9.10.1 What Type?
*
A
B
C
9.11 Do you consume alcohol regularly?
*
Yes
No
9.11.1 Feel free to describe
*
9.12 Have you had your gallbladder or any other organ removed by surgery?
*
Yes
No
9.12.1 Please Specify and include approx date.
*
10.1 Do you get chest pains or angina?
*
Yes
No
10.2 Have you ever had a heart attack (Myocardial Infarction)?
*
Yes
No
10.3 Have you ever had a open-heart surgery?
*
Yes
No
10.4 Do you have heart arrhythmia's?
*
Yes
No
10.4.1 What kind of?
*
10.5 Do you feel pressure on your chest?
*
Yes
No
10.6 Do you get "prickly" pains anywhere, especially in the heart area?
*
Yes
No
10.7 Do you have, or have you ever has High Blood Pressure?
*
Yes
No
10.8 Do you have:
*
Pacemaker
Stents
N/A
11.1 Do you get or have skin rashes?
*
Yes
No
11.2 Do you get skin blemishes?
*
Yes
No
11.3 Do you have Eczema or Dermatitis?
*
Yes
No
11.4 Do you have Psoriasis?
*
Yes
No
11.5 Do you itch anywhere?
*
Yes
No
11.5.1 Where
*
11.6 Is your skin dry?
*
Yes
No
11.7 Is your skin excessive oily?
*
Yes
No
11.8 Do you get or have dandruff?
*
Yes
No
11.9 Do you have any other skin problems?
*
Yes
No
11.9.1 What type?
*
12.1 Do you have hair loss or are you bald or going bald?
*
Yes
No
12.2 Have you ever had Lymph Nodes removed?
*
Yes
No
12.2.1 Where and how many?
*
12.3 Do you have any gray hair?
*
Yes
No
12.4 Do you have a hard time remembering things?
*
Yes
No
12.5 Do you ever get colds or flu-like symptoms?
*
Yes
No
12.6 Do you have fibromyalgia or sclerpderma?
*
Yes
No
12.7 Do you have sinus problems?
*
Yes
No
12.8 Do you have or get sore throats?
*
Yes
No
12.9 Do you have swollen lymph nodes?
*
Yes
No
12.10 Do you have or have you had tumors?
*
Yes
No
12.10.1 Where?
*
12.10.2 Type
*
Fatty
Benign
Malignant
12.11 Do you have a low platelet count (blood)?
*
Yes
No
12.12 Have you had appendicitis or an appendectomy?
*
Yes
No
12.12.1 When?
*
12.13 Do you get boils, pimples, cysts, etc.?
*
Yes
No
12.14 Do you get regular exercise?
*
Yes
No
12.14.1 What type of exercise and how many times per week?
*
12.15 Have you ever had abscesses?
*
Yes
No
12.16 Have you ever had toxemia?
*
Yes
No
12.17 Do you have, or have you had, cellulitis? (not cellulite - this is different!)
*
Yes
No
12.18 Have you ever had gout?
*
Yes
No
12.19 Do you get blurred vision?
*
Yes
No
12.20 Do you have mucus in your eyes when you wake up in the morning?
*
Yes
No
12.21 Do you snore?
*
Yes
No
12.22 Do you have sleep apnea?
*
Yes
No
12.23 Have you had your tonsils out?
*
Yes
No
12.23.1 What age?
*
Kidneys and Bladder
13.1 Have you ever had a urinary tract infection (UTI´s)?
*
Yes
No
13.2 Have you ever had "burning" upon urination?
*
Yes
No
13.3 Do you have problems holding your baldder? (parathyroid)
*
Yes
No
13.4 Have you ever had kidney stones?
*
Yes
No
13.5 Do you have bags under your eyes (esp. in the morning)?
*
Yes
No
13.6 Is your urine flow restricted?
*
Yes
No
13.7 Do you get cramping or pain on either side of your mid-to-lower back?
*
Yes
No
13.8 Do you or did you ever have nephritis?
*
Yes
No
13.9 Do you have lower back weakness?
*
Yes
No
13.10 Do you have or have you had sciatica?
*
Yes
No
13.11 Do you or did you ever have cystitis?
*
Yes
No
Lungs
14.1 Do you get or have (or have had) bronchitis?
*
Yes
No
14.2 Do you get or have (or have had) emphysema?
*
Yes
No
14.3 Do you get or have (or have had) asthma?
*
Yes
No
14.4 Do you get or have (or have had) C.O.P.D.?
*
Yes
No
14.5 Are you on inhalers or nebulizers?
*
Yes
No
14.5.1 How often?
*
14.5.2 What medication?
*
14.5.3 Your oxygen saturation level is:
*
14.6 Do you have pain when you breathe?
*
Yes
No
14.7 Do you have pain when you take a deep breath? (adrenals)
*
Yes
No
14.8 Is it difficult to take a deep breathe?
*
Yes
No
14.9 Did you ever or do you have lung cancer?
*
Yes
No
14.9.1 When?
*
14.10 Do you or did you have a collapsed lung?
*
Yes
No
14.10.1 When?
*
14.11 Are you a smoker?
*
Yes
No
14.11.1 How many cigarettes per day?
*
14.12 Have you ever had pneumonia?
*
Yes
No
14.12.1 When and how often?
*
14.13 Have you ever worked around toxic chemicals, in coal mines or around asbestos?
*
Yes
No
14.14 Do you cough a lot?
*
Yes
No
14.15 Do you remove any mucus when you cough?
*
Yes
No
14.15.1 What color is the mucus?
*
Environmental and other Toxins
15.1 Have you received any vaccines NOT INCLUDING the COV19 Vacciness?
*
Yes
No
15.1.2 Have you received any COV19 Vaccines?
*
Yes
No
When did you receive each?
*
1st Shot
2nd Shot
3rd Shot
15.2 have you had shots for traveling to foreign countries?
*
Yes
No
15.3 Have you had Flu shots?
*
Yes
No
15.4 Do you have mercury Amalgams?
*
Yes
No
15.5 Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals
*
Yes
No
15.6 Have you had Radiaton or Chemotheraphy?
*
Radiaton
Chemotherapy
None
15.6.1 If so, how many treatments?
*
15.7 Have you ever used any form of recreational drugs?
*
Yes
No
15.7.1 Which drugs?
*
15.7.2 Do you still use them?
*
Yes
No
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