Free Health Analysis
Copy this Health Questionnaire to Word Perfect and e-mail it to us or you can send it by post.
We will send you a free confidential computerized health analysis and chemistry report.
It will contain a supplementation schedule and a dietary and exercise recommendation.
BIOTICS SYSTOM HISTORY QUESTIONNAIRE
1138 BURGUNDY LANE OTTAWA ONT. K1C-2M8
Patient Symptom History
CIRCLE ANY OF THE FOLLOWING MEDICATIONS YOU ARE TAKING:
*Antacids *Chemotherapy *Hormones *Relaxants/Sleeping pills
*Antibiotics/Antifungals *Cortisone Anti-inflammatories *Laxatives *Recreational Drugs (Specify)
*Antidepressants *Diuretics *Lithium *Ulcer Medications
*Antidiabetic/Insulin *Heart Medications *Oral *Aspirin or Tylenol
*High Blood Pressure *Thyroid *Contraceptives *Other (Specify)
CIRCLE IF YOU EAT, DRINK, OR USE:
*Alcohol *Distilled Water *Milk Products
*Candy or Refined Sugar *Fluoridated/Chlorinated Water *Refined (white) Flour
*Carbonated Beverages *Frequent Fast Food Restaurants *Salt Food Without Tasting
*Chemical Exposure *Luncheon Meat *Under Excessive Stress
*Cigarettes or Exposure to *Margarine * Sweeteners
*Coffee *Tea *Tobacco (chewing)
*Vitamins & Minerals (Specify Below)
DIRECTIONS : Please read each description and fill in the number that best describes the frequency of your symptoms
within the past year. If you do not understand a symptom, put a "?" before the symptom's number.
When done add each Section and put the total in the Total box.
READ THESE INSTRUCTIONS ON HOW TO FILL OUT YOUR FORM CAREFULLY!!!
Leave Blank if symptoms Never occur
Put a 1 if symptoms are Mild (Occurs once a month or less)
Put a 2 if symptoms are Moderate (Occurs several times monthly)
Put a 3 if symptoms are Severe (Aware of it almost constantly)
IMPORTANT - list your five mayor health concerns in order of importance and/or any medications you are taking.
1._______________________________________ 4. ______________________________________
2._______________________________________ 5. ______________________________________
How many Dental Amalgam Silver fillings do you have?_________________________________________
Do you have any Root Canals?___________ If yes, how many?_____Crowns?________Bridges?________
_____A.01. History of constipation?
_____A.02. Bad breath/halitosis?
_____A.03. Loss of taste for meat?
_____A.04. Belching shortly after meals?
_____A.05. Bloating or gas shortly after meals?
____Total Section A
_____B.01. Burning or gnawing stomach pain?
_____B.02. Heartburn or indigestion after meals?
_____B.03. Stomach pain from stress and/or spicy foods?
_____B.04. Told you have Ulcers?
_____B.05. Use antacids or aspirin?
_____B.06. Use milk or carbonated drinks to relieve stomach pain?
_____Total Section B
_____C.01. Remnants of food or fibers in stools?
_____C.02. Nausea or diarrhea?
_____C.03. Mucus in stools?
_____C.04. Pass gas frequently?
_____Total Section C
_____D.01. Pain or discomfort in abdomen area?
_____D.02. Have allergies?
_____D.03. Self or Family history of autoimmune disease?
_____D.04. Drink alcohol?
_____D.05. Drink milk or eat dairy products?
_____D.06. Often have constipation or diarrhea?
_____D.07. Frequently have gas?
_____Total Section D
_____E.01. Coated or fuzzy debris on tongue?
_____E.02. Bowel movements painful or difficult?
_____E.03. Irritable bowel or colitis?
_____E.04. Have bad breath?
_____ Total Section E
_____F.01. Burning or itching anus?
_____F.02. Frequently get skin eruptions or bumps?
_____F.03. History of yeast infections, antibiotic use?
_____F.04. Use or have used estrogen compounds?
_____F.05. Have intestinal pain for no apparent reason?
_____F.06. Have diarrhea?
_____F.07. Have allergies or sensitivities?
_____F.08. Get sick often or stay sick?
_____F.09. Feel tired all the time?
_____Total Section F
_____G.01. Pain or discomfort on right side under ribcage?
_____G.02. Blurred vision?
_____G.03. Intolerance to greasy foods?
_____G.04. Eat fast food?
_____G.05. Tightness or pain between shoulder blades?
_____G.06. Light-colored or foul smelling stools?
_____G.07. Feel nauseous or queasy after eating fatty foods?
_____G.08. Drink coffee?
_____G.09. Dry skin, itchy or peeling feet?
_____G.10. Retaining water?
_____G.11. Gag easily?
_____G.12. Sour or metallic taste in mouth?
_____Total Section G
_____H.01. Feet burn?
_____H.02. Noises in head or ringing in the ears?
_____H.03. Strong light irritates eyes?
_____H.04. Drink alcohol?
_____H.05. Sensitive to fumes, smoke, smells, or chemicals?
_____H.06. Thick stringy mucus or swollen lymph nodes?
_____H.07. Have allergies?
_____H.08. Eat luncheon meat?
_____H.09. Bronzing of skin or brown spots?
_____Total Section H
_____I.01. Head congestion or sinus fullness?
_____I.02. Frequent sneezing?
_____I.03. Eyes and nose watery, swollen or puffy?
_____I.04. Nightmare-like dreams?
_____I.05. Dark circles under eyes?
_____I.06. Certain foods cause distress (dairy, corn, wheat)?
_____I.07. Sensitive to fumes, smoke or chemicals?
_____I.08. Thick mucus or swollen lymph nodes?
_____I.09. Chronic sinus infections?
_____Total Section I
_____J.01. Crave sweets or coffee in afternoon or mid-morning?
_____J.02. Hungry between meals or excessive appetite?
_____J.03. Irritable before meals or if meals delayed?
_____J.04. Get shaky or light-headed if meals delayed?
_____J.05. Wake in the night and can't go back to sleep?
_____J.06. Problems with memory in mid-morning or after noon?
_____J.07. Eat sweets, refined foods, or fast foods?
_____Total Section J
_____K.01. Family history of diabetes?
_____K.02. Excessive thirst?
_____K.03. Excessive urination?
_____K.04. Fasting glucose greater than 120 mg/dl?
_____K.05. Overweight by 50 or more pounds?
_____Total Section K
_____L.01. Difficulty maintaining chiropractic adjustments?
_____L.02. Crave salt?
_____L.03. Low blood pressure?
_____L.04. Weakness after colds or slow recovery?
_____L.05. Headaches in afternoon?
_____L.06. Muscular or nervous exhaustion?
_____L.07. Chronic fatigue or slow starter in the morning?
_____L.08. Have allergies or sensitivities?
_____Total Section L
_____M.01. Have anxiety?
_____M.02. Problems sleeping or insomnia?
_____M.03. Crave sweets or coffee in the afternoon or mid-morning?
_____M.04. Get shaky or light-headed if meals delayed?
_____M.05. Retain water?
_____M.06. Are under a lot of stress?
_____M.07. Feel tired or sleepy in afternoon?
_____M.08. Eat refined flour products, sugar or drink coffee?
_____Total Section M
_____N.01. Hair and skin dry but not coarse?
_____N.02. Weight gain around hips and waist?
_____N.03. Sex drive reduced or absent?
_____N.04. Impotence or decrease in size of testes (males).
_____N.05. Infertile or decrease in size of breasts (females).
_____N.06. Abnormal thirst?
_____N.07. Lack of menstruation (females)?
_____Total Section N
_____O.01. Feel worse after chiropractic adjustment?
_____O.02. Forgetful, mental sluggishness, or reduced initiative?
_____O.03. Skin coarse and dry?
_____O.04. Cold hands and feet?
_____O.05. Frequent constipation?
_____O.06. Headaches upon awakening?
_____O.07. Gain weight easily?
_____O.08. Cry easily, worse with change in season?
_____O.09. Hair thin or falling out?
_____O.10. Feel depressed?
_____Total Section O
Only Females Answer Section P
_____P.01. Menstruates too frequently?
_____P.02. Acne worse at menses?
_____P.03. Scanty or missed menses?
_____P.04. Painful or tender breasts?
_____P.05. Have had hysterectomy?
_____P.06. Mood changes or irritability before menses?
_____P.07. Painful menses or cramping during menses?
_____P.08. Menstruation excessive or prolonged?
_____P.09. Menopausal depression?
_____P.10. Have hot flashes?
_____P.11. Depression before menses?
_____Total Section P
Only Males Answer Section Q
_____Q.01. History of prostate problems?
_____Q.02. Decreased size and force of urinary stream?
_____Q.03. Reduced sex drive?
_____Q.04. Dribbling after urination?
_____Q.05. Frequent night urination?
_____Q.06. Feeling of incomplete bowel evacuation?
_____Q.07. Difficulty stopping urinary flow?
_____Q.08. Leg nervousness at night?
_____Q.09. Pain on side of legs or on inside of heels?
_____Total Section Q
_____R.01. Chest pain or shortness of breath on exertion?
_____R.02. Swollen ankles, worse at night?
_____R.03. Personal or family history or cardiovascular disease?
_____R.04. High cholesterol or triglycerides?
_____R.05. Pain under sternum that radiates to the left shoulder?
_____R.06. Air hunger, sigh frequently or labored breathing?
_____R.07. Irregular heartbeat?
_____R.08. Snores while sleeping?
_____R.09. Pain, cramp or tired feeling in foot, calf and hip?
___Total Section R
_____S.01. Have bronchial asthma or bronchitis?
_____S.02. Frequent lung congestion?
_____S.03. Live or work around people who smoke?
_____S.04. Recurrent sinus or upper-respiratory infections?
_____S.05. Chronic cough?
_____Total Section S
_____T.01. Recurrent bladder or kidney infections?
_____T.02. Painful burning when passing urine?
_____T.03. Cloudy, rose-colored, or strong-smelling urine?
_____T.04. Difficulty urinating?
_____T.05. Urinary leakage or bedwetting?
_____T.06. Back pain in kidney area?
_____T.07. History of kidney problems?
_____T.08. Have skin eruptions such as psoriasis or eczema?
_____Total Section T
_____U.01. Pain in neck or shoulders?
_____U.02. Tightness in shoulder muscles?
_____U.03. Muscle cramps or spasms?
_____U.04. Muscles and joints sore all over?
_____Total Section U
_____V.01. Joint pain in hands or fingers?
_____V.02. Told you have arthritis?
_____V.03. Joint stiffness?
_____V.04. Told you have herniated or slipped disc?
_____Total Section V
_____W.01. Bones are sore or pain in fingers?
_____W.02. Cavities or dentures?
_____W.03. Gums bleed easily?
_____W.04. Have muscle cramps?
_____W.05. Told you have bone loss or Osteoporosis?
_____Total Section W
_____X.01. Uncoordinated or unsteady walk?
_____X.02. Pins and needle burning sensation in in hands or feet?
_____X.03. Muscle weakness or reflex loss?
_____X.04. Loss of sense of vibration in legs?
_____X.05. Memory loss?
_____X.06. Restless leg?
_____X.08. Irritable or moody?
_____Total Section X
_____Y.01. Chronic infections?
_____Y.02. Wounds heal slowly?
_____Y.03. Loss of sense of taste and smell?
_____Y.05. White spots under fingernails?
_____Total Section Y
_____ZA.01. Night vision poor?
_____ZA.02. Strong light irritates eyes?
_____ZA.03. Noises in head or ringing in ears?
_____Total Section ZA
_____ZB.01. Vulnerable to insect bites?
_____ZB.02. Loss of muscle tone or heaviness in arms and legs?
_____ZB.03. Worrier, feel insecure, or highly emotional?
_____ZB.04. Slow pulse or irregular heartbeat?
_____ZB.05. Poor appetite?
_____Total Section ZB
_____ZC.01. Burning sensation in mouth?
_____ZC.02. Cannot recall dreams?
_____ZC.03. Numbness in hands and/or feet?
_____ZC.04. Intolerance to MSG?
_____Total Section ZC
_____ZD.01. Intolerance to sulfites (found in wine)?
_____ZD.02. Sensitive to perfumes or smells?
_____Total Section ZD
_____ZE.01. Frequently irritable?
_____ZE.02. Easily startled or nervous?
_____ZE.03. Muscle, leg, or toe cramping at rest?
_____ZE.04. Body odor or foot odor?
_____ZE.05. Crave chocolate?
_____Total Section ZE
_____ZF.01. "Lump" in throat?
_____ZF.02. Dry mouth, eyes or nose?
_____ZF.03. Gag easily?
_____Total Section ZF
_____ZG.01. Fatigued all the time?
_____ZG.02. Nails weak or ridged?
_____ZG.03. History of anemia?
_____ZG.04. Hands and feet often cold?
_____ZG.05. Crave ice?
_____ZG.06. "Whites of eyes are blue tinted?
_____Total Section ZG
_____ZH.01. Gums bleed easily?
_____ZH.02. Bruise easily?
_____Total Section ZH
_____ZI.01. Poor wound healing?
_____ZI.02. Dry skin?
_____ZI.03. Vision blurred or impaired?
_____ZI.04. Chronic infections?
_____ZI.05. Frequent skin problems?
_____Total Section ZI
The results of this health analysis can take up to a week for a reply.
Call or e-mail email@example.com
As a Natural Health Consultant, Ron will be happy to answer any questions on health and nutrition.
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