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HEALTH QUESTIONAIRE
 
 
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The Health Questionnaire is an easy to fill out tool that can help you and Dr Wolf assess the different organ systems of your body. If you are a patient of Dr Wolf�s or are soon to be a patient it is essential to fill out this form. If you are not a patient and are just interested in how your body is functioning you can also fill out the form and view the results.

The form is divided into 16 sections covering a specific part of the body e.g. liver, heart etc. There are also sections that indicate information about vitamin and mineral needs. Each section will give you a score which indicates symptom burden of a specific system: low, moderate or high priority of symptoms Moderate to high priority means that your body is overloaded in a specific system and some action should be taken to correct this. Once you have filled out the form just click on to the corresponding links that discusses each specific system to read more detailed information about that section. It is important to note that this is not a diagnostic tool and will not give you a diagnosis of your complaints. It is only an indicator of symptom burden.

All health questionnaires results are sent to Dr Wolf for verification and if you have scored a moderate or high priority result you will be sent an email requesting you to make an appointment to correct the symptom burdens. Current patient s will be sent a sms reminder every 3 months to fill in and review the questionnaire. This will give you and Dr Wolf an indication of your health progress on an annual basis.

Questionnaire

Name: Date: / /
Email: Gender:
Tel: Birth Date: / /
Cell:

Please list your five major health concerns in order of importance: Notes:
1.
2.
3.
4.
5.

Read the questions and select the number that applies. You can opt to ignore any section.

KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly)
  1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily)

1. Upper Gastrointestinal Section   (ignore section)

1. Belching or gas within one hour after eating
2. Heartburn or acid reflux
3. Bloating within one hour after eating
4. Vegan diet (no dairy, meat, fish or eggs) (0=no, 1=yes)
5. Bad breath (halitosis)
6. Loss of taste for meat
7. Sweat has a strong odor
8. Stomach upset by taking vitamins
9. Sense of excess fullness after meals
10. Feel like skipping breakfast
11. Feel better if you don�t eat
12. Sleepy after meals
13. Fingernails chip, peel or break easily
14. Anemia unresponsive to iron
15. Stomach pains or cramps
16. Diarrhea, chronic
17. Diarrhea shortly after meals
18. Black or tarry colored stools
19. Undigested food in stool


2. Liver and Gallbladder Section   (ignore section)

20. Pain between shoulder blades
21. Stomach upset by greasy foods
22. Greasy or shiny stools
23. Nausea
24. Sea, car, airplane or motion sickness
25. History of morning sickness (0 = no, 1 = yes)
26. Light or clay colored stools
27. Dry skin, itchy feet or skin peels on feet
28. Headache over eyes
29. Gallbladder attacks (0=never, 1=years ago, 2=within last year, 3=within past 3 months)
30. Gallbladder removed (0=no, 1=yes)
31. Bitter taste in mouth, especially after meals
32. Become sick if you were to drink wine (0=no, 1=yes)
33. Easily intoxicated if you were to drink wine (0=no, 1=yes)
34. Easily hung over if you were to drink wine (0=no, 1=yes)
35. Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14)
36. Recovering alcoholic (0=no, 1=yes)
37. History of drug or alcohol abuse (0=no, 1=yes)
38. History of hepatitis (0=no, 1=yes)
39. Long term use of prescription/recreational drugs (0=no, 1=yes)
40. Sensitive to chemicals (perfume, cleaning agents, etc.)
41. Sensitive to tobacco smoke
42. Exposure to diesel fumes
43. Pain under right side of rib cage
44. Hemorrhoids or varicose veins
45. Nutrasweet (aspartame) consumption
46. Sensitive to Nutrasweet (aspartame)
47. Chronic fatigue or Fibromyalgia


3. Small Intestine Section   (ignore section)

48. Food allergies
49. Abdominal bloating 1 to 2 hours after eating
50. Specific foods make you tired or bloated (0=no, 1=yes)
51. Pulse speeds after eating
52. Airborne allergies
53. Experience hives
54. Sinus congestion, "stuffy head"
55. Crave bread or noodles
56. Alternating constipation and diarrhea
57. Crohn's disease (0 =no, 1=yes in the past, 2=currently mild condition, 3=severe)
58. Wheat or grain sensitivity
59. Dairy sensitivity
60. Are there foods you could not give up (0=no, 1=yes)
61. Asthma, sinus infections, stuffy nose
62. Bizarre vivid dreams, nightmares
63. Use over-the-counter pain medications
64. Feel spacey or unreal

KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly)
  1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily)


4. Large Intestine Section   (ignore section)

65. Anus itches
66. Coated tongue
67. Feel worse in moldy or musty place
68. Taken antibiotic for a total accumulated time of (0=never, 1= <1 month, 2= <3 months, 3= >3 months)
69. Fungus or yeast infections
70. Ring worm, "jock itch", "athletes foot", nail fungus
71. Yeast symptoms increase with sugar, starch or alcohol
72. Stools hard or difficult to pass
73. History of parasites (0=no, 1=yes)
74. Less than one bowel movement per day
75. Stools have corners or edges, are flat or ribbon shaped
76. Stools are not well formed (loose)
77. Irritable bowel or mucus colitis
78. Blood in stool
79. Mucus in stool
80. Excessive foul smelling lower bowel gas
81. Bad breath or strong body odors
82. Painful to press along outer sides of thighs (Iliotibial Band)
83. Cramping in lower abdominal region
84. Dark circles under eyes


5. Minerals Needs Section   (ignore section)

85. History of carpal tunnel syndrome (0=no, 1=yes)
86. History of lower right abdominal pains or ileocecal valve problems (0=no, 1=yes)
87. History of stress fracture (0=no, 1=yes)
88. Bone loss (reduced density on bone scan)
89. Are you shorter than you used to be? (0=no, 1=yes)
90. Calf, foot or toe cramps at rest
91. Cold sores, fever blisters or herpes lesions
92. Frequent fevers
93. Frequent skin rashes and/or hives
94. Herniated disc (0=no, 1=yes)
95. Excessively flexible joints, "double jointed"
96. Joints pop or click
97. Pain or swelling in joints
98. Bursitis or tendonitis
99. History of bone spurs (0=no, 1=yes)
100. Morning stiffness
101. Nausea with vomiting
102. Crave chocolate
103. Feet have a strong odor
104. History of anemia
105. Whites of eyes (sclera) blue tinted
106. Hoarseness
107. Difficulty swallowing
108. Lump in throat
109. Dry mouth, eyes and/or nose
110. Gag easily
111. White spots on fingernails
112. Cuts heal slowly and/or scar easily
113. Decreased sense of taste or smell


6. Essential Fatty Acids Section   (ignore section)

114. Experience pain relief with aspirin (0=no, 1=yes)
115. Crave fatty or greasy foods
116. Low- or reduced-fat diet (0=never, 1=years ago, 2=within past year, 3=currently)
117. Tension headaches at base of skull
118. Headaches when out in the hot sun
119. Sunburn easily or suffer sun poisoning
120. Muscles easily fatigued
121. Dry flaky skin or dandruff


7. Sugar Handling Section   (ignore section)

122. Awaken a few hours after falling asleep, hard to get back to sleep
123. Crave sweets
124. Binge or uncontrolled eating
125. Excessive appetite
126. Crave coffee or sugar in the afternoon
127. Sleepy in afternoon
128. Fatigue that is relieved by eating
129. Headache if meals are skipped or delayed
130. Irritable before meals
131. Shaky if meals delayed
132. Family members with diabetes (0=none, 1=1 or 2, 2=3 or 4, 3=more than 4)
133. Frequent thirst
134. Frequent urination

KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly)
  1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily)


8. Vitamin Need Section   (ignore section)

135. Muscles become easily fatigued
136. Feel exhausted or sore after moderate exercise
137. Vulnerable to insect bites
138. Loss of muscle tone, heaviness in arms/legs
139. Enlarged heart or congestive heart failure
140. Pulse below 65 per minute (0=no, 1=yes)
141. Ringing in the ears (Tinnitus)
142. Numbness, tingling or itching in hands and feet
143. Depressed
144. Fear of impending doom
145. Worrier, apprehensive, anxious
146. Nervous or agitated
147. Feelings of insecurity
148. Heart races
149. Can hear heart beat on pillow at night
150. Whole body or limb jerk as falling asleep
151. Night sweats
152. Restless leg syndrome
153. Cracks at corner of mouth (Cheilosis)
154. Fragile skin, easily chaffed, as in shaving
155. Polyps or warts
156. MSG sensitivity
157. Wake up without remembering dreams
158. Small bumps on back of arms
159. Strong light at night irritates eyes
160. Nose bleeds and/or tend to bruise easily
161. Bleeding gums especially when brushing teeth


9. Adrenal Section   (ignore section)

162. Tend to be a "night person"
163. Difficulty falling asleep
164. Slow starter in the morning
165. Tend to be keyed up, trouble calming down
166. Blood pressure above 120/80
167. Headache after exercising
168. Feeling wired or jittery after drinking coffee
169. Clench or grind teeth
170. Calm on the outside, troubled on the inside
171. Chronic low back pain, worse with fatigue
172. Become dizzy when standing up suddenly
173. Difficulty maintaining manipulative correction
174. Pain after manipulative correction
175. Arthritic tendencies
176. Crave salty foods
177. Salt foods before tasting
178. Perspire easily
179. Chronic fatigue, or get drowsy often
180. Afternoon yawning
181. Afternoon headache
182. Asthma, wheezing or difficulty breathing
183. Pain on the medial or inner side of the knee
184 Tendency to sprain ankles or "shin splints"
185. Tendency to need sunglasses
186. Allergies and/or hives
187. Weakness, dizziness


10. Pituitary Section   (ignore section)

188. Height over 6' 6" (0=no, 1=yes)
189. Early sexual development (before age 10) (0=no, 1=yes)
190. Increased libido
191. Splitting type headache
192. Memory failing
193. Tolerate sugar, feel fine when eating sugar (0=no, 1=yes)
194. Height under 4' 10" (0=no, 1=yes)
195. Decreased libido
196. Excessive thirst
197. Weight gain around hips or waist
198. Menstrual disorders
199. Delayed sexual development (after age 13) (0=no, 1=yes)
200. Tendency to ulcers or colitis

KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly)
  1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily)


11. Thyroid Section   (ignore section)

201. Sensitive/allergic to iodine
202. Difficulty gaining weight, even with large appetite
203. Nervous, emotional, can't work under pressure
204. Inward trembling
205. Flush easily
206. Fast pulse at rest
207. Intolerance to high temperatures
208. Difficulty losing weight
209. Mentally sluggish, reduced initiative
210. Easily fatigued, sleepy during the day
211. Sensitive to cold, poor circulation (cold hands and feet)
212. Constipation, chronic
213. Excessive hair loss and/or coarse hair
214. Morning headaches, wear off during the day
215. Loss of lateral 1/3 of eyebrow
216. Seasonal sadness

12. Men Only Section   (ignore section)

217. Prostate problems
218. Difficulty with urination, dribbling
219. Difficult to start and stop urine stream
220. Pain or burning with urination
221. Waking to urinate at night
222. Interruption of stream during urination
223. Pain on inside of legs or heels
224. Feeling of incomplete bowel evacuation
225. Decreased sexual function

13. Women Only Section   (ignore section)

226. Depression during periods
227. Mood swings associated with periods (PMS)
228. Crave chocolate around periods
229. Breast tenderness associated with cycle
230. Excessive menstrual flow
231. Scanty blood flow during periods
232. Occasional skipped periods
233. Variations in menstrual cycles
234. Endometriosis
235. Uterine fibroids
236. Breast fibroids, benign masses
237. Painful intercourse (dysparenia)
238. Vaginal discharge
239. Vaginal dryness
240. Vaginal itchiness
241. Gain weight around hips, thighs and buttocks
242. Excess facial or body hair
243. Hot flashes
244. Night sweats (in menopausal females)
245. Thinning skin

14. Cardiovascular Section   (ignore section)

246. Aware of heavy and/or irregular breathing
247. Discomfort at high altitudes
248. "Air hunger" or sigh frequently
249. Compelled to open windows in a closed room
250. Shortness of breath with moderate exertion
251. Ankles swell, especially at end of day
252. Cough at night
253. Blush or face turns red for no reason
254. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
255. Muscle cramps with exertion


15. Kidney and Bladder Section   (ignore section)

256. Pain in mid-back region
257. Puffy around the eyes, dark circles under eyes
258. History of kidney stones (0=no, 1=yes)
259. Cloudy, bloody or darkened urine
260. Urine has a strong odor


16. Immune System Section   (ignore section)

261. Runny or drippy nose
262. Catch colds at the beginning of winter
263. Mucus producing cough
264. Frequent colds or flu (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year)
265. Other infections (sinus, ear, lung, skin, bladder, kidney, etc.) (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year)
266. Never get sick (0 = sick only 1 or 2 times in last 2 years, 1 = not sick in last 2 years, 2 = not sick in last 4 years, 3 = not sick in last 7 years)
267. Acne (adult)
268. Itchy skin (Dermatitis)
269. Cysts, boils, rashes
270. History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition (0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe)


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