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                                CLIENT INFORMATION
Name____________________________________________ Ht. ________ Wt. _________ Age ______

Address _______________________________ City ____________ State________ Zip ____________

D.O.B. ________________________Social Security Number (optional)__________________________

Home Phone ___________________ Work Phone __________________ Fax _____________________

Employment ___________________ Family Physician _______________Cardiologist______________


                              HEALTH QUESTIONNAIRE
                                A SELF-ASSESSMENT

       What is Your Body Telling You?

       Yes        No         Thyroid/Parathyroid (Glandular System)
        yes        no        Are you overweight?
        yes        no        Do you get cold hands and feet?
        yes        no        Do you have hair loss or are you bald or going bald?
        yes        no        Is it easy to put on weight and hard to loose it?
        yes        no        Are your fingernails ridged, brittle or weak?
        yes        no        Do you have varicose or spider veins?
        yes        no        Do you, or have you had hemorrhoids?
        yes        no        Do you get cramping in your muscles?
        strong     weak      Is your bladder strong or weak?
        yes        no        Do you have an irregular heartbeat?
        yes        no        Do you have Mitral Valve Prolapse (Heart Murmur)?
        yes        no        Do you get headaches or migraines?
        yes        no        Have you now have, or have you ever had a hernia?
        yes        no        Have you ever had an aneurysm?
        yes        no        Do you have osteoporosis?
        yes        no        Do you have scoliosis?
        yes        no        Do you get irritable easily?
Yes      No        Thyroid/Parathyroid (Glandular System Continued)
 yes      no       Do you have low energy levels?
 yes      no       Do you suffer from symptoms of depression?
 yes      no       Did you score low on your bone density tests?
 yes      no       Do your tests come back showing Low Calcium levels?
 yes      no       Do you have, or have you ever had, a goiter?
 yes      no       Do you have spine deterioration or herniated discs?
 yes      no       Have you been diagnosed with Hashimoto or Reidel disease? (Or any
                   family member?)
 a lot    little   Do you sweat profusely or hardly at all?



Yes      No        Adrenal Glands (Glandular System)
                   Medulla (Adrenal)
 yes      no       Do you have M.S., Parkinson’s or Palsy?
 yes      no       Do you have anxiety attacks, or feel overly anxious?
 yes      no       Do you feel excessive shyness, or inferior to others?
 yes      no       Do you have low blood pressure (below 118 systolic)?
 yes      no       Do you have tremors, nervous legs, etc.?
 yes      no       Do you have tinnitis (ringing in the ears)?
 yes      no       Do you have S.O.B. (shortness of breath) or is it hard to take a deep
                   breath?
 yes      no       Do you have heart arrhythmias?
 yes      no       Do you have a hard time sleeping?
 yes      no       Do you have Chronic Fatigue Syndrome?
 yes      no       Do you get tired easily?
 yes      no       Have you ever been diagnosed with Addison’s Disease or with
                   Congenital Adrenal Hyperplasia?
                   Cortex (Adrenal)
 yes      no       Do you have elevated blood cholesterol levels?
 yes      no       Do you have lower back weakness?
 yes      no       Do you have, or have you had, sciatica?
 yes      no       Do you have arthritis or bursitis?
 yes      no       Do you have any “itis’s (inflammatory conditions)?
                   Explain
                   _________________________________________________________
                   _________________________________________________________
Yes    No    Female Only
 yes    no   Are your menstruation’s irregular?
 yes    no   Do you get excessive bleeding during menstruation?
 yes    no   Do you have or have you had ovarian cysts?
 yes    no   Do you have or did you have fibroids?
 yes    no   Do you have or did you have endometriosis or A-typical cells?
 yes    no   Are you fibrocystic?
 yes    no   Do you have fibromyalgia or scleroderma?
 yes    no   Do you get sore breasts, especially during menstruation?
 yes    no   Do you have a low or excessive sex drive?
 yes    no   Have you had a hysterectomy? When______________?
             Partial _____       Complete _____

 yes    no   Did they take any other organs out at the same time? ( c.a.
             gallbladder)
 yes    no   Have you had a D & C?
 yes    no   Have you had a miscarriage?
 yes    no   Have you had difficulty in conceiving children?
ÅÅÅ ÅÅÅ      Other


Yes    No    Male Only
 yes    no   Do you have prostatitis (frequent urination esp. at night)?
             If yes, how often?
 yes    no   Do you have prostate cancer? PSA count’s ____________
 yes    no   Do you have testicular hypertrophy (enlargement)?
 yes    no   Do you have a low or excessive sex drive?
 yes    no   Do you have erection problems?
 yes    no   Do you have premature ejaculation?
ÄÄÄ ÄÄÄ      Other


Yes    No    Pancreas
 yes    no   Do you get gas after you eat?
 yes    no   Do you feel your foods just sitting in your stomach?
 yes    no   Do you have Acid Reflux?
 yes    no   Do you see any undigested foods in your stools?
 yes    no   Do you have hypoglycemia (Low Blood Sugar)?
 yes    no   Do you have Diabetes (High Blood Sugar)?
Type I ___    or    Type II ___

Yes    No    Pancreas (Continued)
 yes    no   Are you thin and have a hard time putting on weight?
 yes    no   Do you have gastritis or enteritis?
 yes    no   Do your foods pass right through you (diarrhea)?
 yes    no   Do you have moles on your body?



Yes    No    Gastro-Intestinal Tract
 yes    no   Is your tongue coated (white, yellow, green or brown), especially in the
             morning?
 yes    no   Do you have a Hiatus Hernia?
 yes    no   Do you have Gastritis?
 yes    no   Do you have Enteritis?
 yes    no   Do you have Colitis?
 yes    no   Do you have Diverticulitis?
 yes    no   Do you get or have Diarrhea?
 yes    no   Do you get or have Constipation?
 yes    no   How often do you have a Bowel Movement?
 yes    no   Have you ever had stomach or intestinal ulcers?
 yes    no   Do you or have you ever had any type of gastro-intestinal cancers:
             stomach, colon, rectal, etc.
             Explain:
 yes    no   Do you have Crohn’s Disease?
 yes    no   Do you have “gas” problems?
 yes    no   Other GI problems:



Yes    No    Liver/Gallbladder/Blood
 yes    no   Do you have a problem digesting fats?
 yes    no   Do fats or dairy foods cause bloating and/or pain in the stomach area?
 yes    no   Are your stools white or very light brown in color?
 yes    no   Do you get pain in the middle of your back (especially after eating)?
 yes    no   Do you get pain behind the right, lower rib area?
 yes    no   Do you have “liver” or brown spots on your skin? (not freckles)
 yes    no   Do you have any skin pigmentation changes?
yes    no   Do you have skin problems? If so, what type?
 yes    no   Are you anemic?
 yes    no   Do you have, or have you ever had, hepatitis? A___, B___, C___.

Yes    No    Heart & Circulation
 yes    no   Do you have any gray hair?
 yes    no   Do you have a hard time remembering things?
 yes    no   Do your legs get tired or cramp after you walk?
 yes    no   Do you bruise easily?
 yes    no   Do you get chest pains or angina?
 yes    no   Have you ever had a heart attack (Myocardial Infarction)?
 yes    no   Have you ever had open-heart surgery?
 yes    no   Do you have heart arrhythmia's?
             What kind?
 yes    no   Do you have a heart murmur or Mitral Valve Prolapse?
 yes    no   Do you ever feel pressure on your chest?
 yes    no   Do you get “prickly” pains anywhere, especially in the heart area?
             Where?_______________________________________________

 yes    no   Do you have, or have you ever had High Blood Pressure?
 yes    no   Your average Blood Pressure is ______ over ______.



Yes    No    Skin
 yes    no   Do you get or have skin rashes?
 yes    no   Do you get skin blemishes?
 yes    no   Do you have Eczema or Dermatitis?
 yes    no   Do you have Psoriasis?
 yes    no   Do you itch anywhere? Where?
 yes    no   Is your skin dry?
 yes    no   Is your skin excessively oily?
 yes    no   Do you get or have dandruff?


Yes    No    Lymphatic System
 yes    no   Are you allergic to anything? What?
 yes    no   Do you ever get colds or flu-like symptoms?
 yes    no   Do you have sinus problems?
 yes    no   Do you have or get sore throats?
yes    no   Do you have swollen lymph nodes?
 yes    no   Do you have or had tumors? What type?
             Fatty_______ Benign_________ Cancerous _________
             Where?_______________________________________

Yes    No    Lymphatic System (continued)
 yes    no   Do you have a low platelet count (blood)?
 yes    no   Is your immune system low or sluggish?
 yes    no   Have you had appendicitis or an appendectomy? When?
 yes    no   Do you get boils, pimples, and the like?
 yes    no   Do you have allergies?
 yes    no   Have you ever had abscesses?
 yes    no   Have you ever had toxemia?
 yes    no   Do you have, or have you had, cellulitis?
 yes    no   Have you ever had gout?
 yes    no   Do you get blurred vision?
 yes    no   Do you have mucus in your eyes when you wake up in the morning?
 yes    no   Do you snore?
 yes    no   Do you have sleep apnea?
 yes    no   Have you had your tonsils out? What age? _________


Yes    No    Kidneys & Bladder
 yes    no   Have you ever had a urinary tract infection (UTI’s)?
 yes    no   Have you ever had “burning” upon urination?
 yes    no   Do you have problems holding your bladder (para-thyroid)?
 yes    no   Have you ever had kidney stones?
 yes    no   Do you have bags under your eyes (esp. in the morning)?
 yes    no   Is your urine flow restricted?
 yes    no   Do you get cramping or pain on either side of your mid-to-lower back?
 yes    no   Do you or did you ever have nephritis?
 yes    no   Do you or did you ever have cystitis?


Yes    No    Lungs
 yes    no   Do you get or have (or have had) bronchitis?
 yes    no   Do you get or have (or have had) emphysema?
 yes    no   Do you get or have (or have had) asthma?
 yes    no   Do you get or have (or have had) C.O.P.D?
yes          no         Are you on inhalers or nebulizers? How often?
                          What type?
 yes           no         Do you know what your oxygen saturation is ________?
 yes           no         Do you get pain when you breathe?
 yes           no         Do you get pain when you take a deep breath?
 yes           no         Did you ever or do you have lung cancer?
Yes          No           Lungs (Continued)
 yes           no         Do you have a collapsed lung?
 yes           no         Are you a smoker? How often?
 yes           no         Have you ever had pneumonia?
 yes           no         Have you ever worked around toxic chemicals, in coal mines or around
                          asbestos?
  yes          no         Do you cough a lot?
  yes          no         Do you get any mucus when you cough?
  yes          no         What color is the mucus?


Other (What are your main health complaints or concerns?)
Please list and elaborate on any conditions or symptoms that this questionnaire has not covered
or asked you.




Past Surgeries
Please list any past surgeries you have had (e.g. tonsils removed, hysterectomies, open heart
surgery, etc.)

Surgery                                                                               Year
Chemical Medications
Please list any chemical medications that you are presently taking:
Medication                                        Reason:




Natural Supplements
Please list any natural supplements you are currently taking:
Supplements                                       Vitamins & Minerals




Allergies
Please list anything that you are allergic to:
Allergy




Genetic History
Mom:
Dad:
(Maternal) Grandfather:
(Maternal) Grandmother:
(Fraternal) Grandfather:
(Fraternal) Grandmother:
Sister:
Sister:
Brother:
Brother:
                           J Thank You J

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Dr morse's self assessment

  • 1. (941) 255-1979 CLIENT INFORMATION Name____________________________________________ Ht. ________ Wt. _________ Age ______ Address _______________________________ City ____________ State________ Zip ____________ D.O.B. ________________________Social Security Number (optional)__________________________ Home Phone ___________________ Work Phone __________________ Fax _____________________ Employment ___________________ Family Physician _______________Cardiologist______________ HEALTH QUESTIONNAIRE A SELF-ASSESSMENT What is Your Body Telling You? Yes No Thyroid/Parathyroid (Glandular System) yes no Are you overweight? yes no Do you get cold hands and feet? yes no Do you have hair loss or are you bald or going bald? yes no Is it easy to put on weight and hard to loose it? yes no Are your fingernails ridged, brittle or weak? yes no Do you have varicose or spider veins? yes no Do you, or have you had hemorrhoids? yes no Do you get cramping in your muscles? strong weak Is your bladder strong or weak? yes no Do you have an irregular heartbeat? yes no Do you have Mitral Valve Prolapse (Heart Murmur)? yes no Do you get headaches or migraines? yes no Have you now have, or have you ever had a hernia? yes no Have you ever had an aneurysm? yes no Do you have osteoporosis? yes no Do you have scoliosis? yes no Do you get irritable easily?
  • 2. Yes No Thyroid/Parathyroid (Glandular System Continued) yes no Do you have low energy levels? yes no Do you suffer from symptoms of depression? yes no Did you score low on your bone density tests? yes no Do your tests come back showing Low Calcium levels? yes no Do you have, or have you ever had, a goiter? yes no Do you have spine deterioration or herniated discs? yes no Have you been diagnosed with Hashimoto or Reidel disease? (Or any family member?) a lot little Do you sweat profusely or hardly at all? Yes No Adrenal Glands (Glandular System) Medulla (Adrenal) yes no Do you have M.S., Parkinson’s or Palsy? yes no Do you have anxiety attacks, or feel overly anxious? yes no Do you feel excessive shyness, or inferior to others? yes no Do you have low blood pressure (below 118 systolic)? yes no Do you have tremors, nervous legs, etc.? yes no Do you have tinnitis (ringing in the ears)? yes no Do you have S.O.B. (shortness of breath) or is it hard to take a deep breath? yes no Do you have heart arrhythmias? yes no Do you have a hard time sleeping? yes no Do you have Chronic Fatigue Syndrome? yes no Do you get tired easily? yes no Have you ever been diagnosed with Addison’s Disease or with Congenital Adrenal Hyperplasia? Cortex (Adrenal) yes no Do you have elevated blood cholesterol levels? yes no Do you have lower back weakness? yes no Do you have, or have you had, sciatica? yes no Do you have arthritis or bursitis? yes no Do you have any “itis’s (inflammatory conditions)? Explain _________________________________________________________ _________________________________________________________
  • 3. Yes No Female Only yes no Are your menstruation’s irregular? yes no Do you get excessive bleeding during menstruation? yes no Do you have or have you had ovarian cysts? yes no Do you have or did you have fibroids? yes no Do you have or did you have endometriosis or A-typical cells? yes no Are you fibrocystic? yes no Do you have fibromyalgia or scleroderma? yes no Do you get sore breasts, especially during menstruation? yes no Do you have a low or excessive sex drive? yes no Have you had a hysterectomy? When______________? Partial _____ Complete _____ yes no Did they take any other organs out at the same time? ( c.a. gallbladder) yes no Have you had a D & C? yes no Have you had a miscarriage? yes no Have you had difficulty in conceiving children? ÅÅÅ ÅÅÅ Other Yes No Male Only yes no Do you have prostatitis (frequent urination esp. at night)? If yes, how often? yes no Do you have prostate cancer? PSA count’s ____________ yes no Do you have testicular hypertrophy (enlargement)? yes no Do you have a low or excessive sex drive? yes no Do you have erection problems? yes no Do you have premature ejaculation? ÄÄÄ ÄÄÄ Other Yes No Pancreas yes no Do you get gas after you eat? yes no Do you feel your foods just sitting in your stomach? yes no Do you have Acid Reflux? yes no Do you see any undigested foods in your stools? yes no Do you have hypoglycemia (Low Blood Sugar)? yes no Do you have Diabetes (High Blood Sugar)?
  • 4. Type I ___ or Type II ___ Yes No Pancreas (Continued) yes no Are you thin and have a hard time putting on weight? yes no Do you have gastritis or enteritis? yes no Do your foods pass right through you (diarrhea)? yes no Do you have moles on your body? Yes No Gastro-Intestinal Tract yes no Is your tongue coated (white, yellow, green or brown), especially in the morning? yes no Do you have a Hiatus Hernia? yes no Do you have Gastritis? yes no Do you have Enteritis? yes no Do you have Colitis? yes no Do you have Diverticulitis? yes no Do you get or have Diarrhea? yes no Do you get or have Constipation? yes no How often do you have a Bowel Movement? yes no Have you ever had stomach or intestinal ulcers? yes no Do you or have you ever had any type of gastro-intestinal cancers: stomach, colon, rectal, etc. Explain: yes no Do you have Crohn’s Disease? yes no Do you have “gas” problems? yes no Other GI problems: Yes No Liver/Gallbladder/Blood yes no Do you have a problem digesting fats? yes no Do fats or dairy foods cause bloating and/or pain in the stomach area? yes no Are your stools white or very light brown in color? yes no Do you get pain in the middle of your back (especially after eating)? yes no Do you get pain behind the right, lower rib area? yes no Do you have “liver” or brown spots on your skin? (not freckles) yes no Do you have any skin pigmentation changes?
  • 5. yes no Do you have skin problems? If so, what type? yes no Are you anemic? yes no Do you have, or have you ever had, hepatitis? A___, B___, C___. Yes No Heart & Circulation yes no Do you have any gray hair? yes no Do you have a hard time remembering things? yes no Do your legs get tired or cramp after you walk? yes no Do you bruise easily? yes no Do you get chest pains or angina? yes no Have you ever had a heart attack (Myocardial Infarction)? yes no Have you ever had open-heart surgery? yes no Do you have heart arrhythmia's? What kind? yes no Do you have a heart murmur or Mitral Valve Prolapse? yes no Do you ever feel pressure on your chest? yes no Do you get “prickly” pains anywhere, especially in the heart area? Where?_______________________________________________ yes no Do you have, or have you ever had High Blood Pressure? yes no Your average Blood Pressure is ______ over ______. Yes No Skin yes no Do you get or have skin rashes? yes no Do you get skin blemishes? yes no Do you have Eczema or Dermatitis? yes no Do you have Psoriasis? yes no Do you itch anywhere? Where? yes no Is your skin dry? yes no Is your skin excessively oily? yes no Do you get or have dandruff? Yes No Lymphatic System yes no Are you allergic to anything? What? yes no Do you ever get colds or flu-like symptoms? yes no Do you have sinus problems? yes no Do you have or get sore throats?
  • 6. yes no Do you have swollen lymph nodes? yes no Do you have or had tumors? What type? Fatty_______ Benign_________ Cancerous _________ Where?_______________________________________ Yes No Lymphatic System (continued) yes no Do you have a low platelet count (blood)? yes no Is your immune system low or sluggish? yes no Have you had appendicitis or an appendectomy? When? yes no Do you get boils, pimples, and the like? yes no Do you have allergies? yes no Have you ever had abscesses? yes no Have you ever had toxemia? yes no Do you have, or have you had, cellulitis? yes no Have you ever had gout? yes no Do you get blurred vision? yes no Do you have mucus in your eyes when you wake up in the morning? yes no Do you snore? yes no Do you have sleep apnea? yes no Have you had your tonsils out? What age? _________ Yes No Kidneys & Bladder yes no Have you ever had a urinary tract infection (UTI’s)? yes no Have you ever had “burning” upon urination? yes no Do you have problems holding your bladder (para-thyroid)? yes no Have you ever had kidney stones? yes no Do you have bags under your eyes (esp. in the morning)? yes no Is your urine flow restricted? yes no Do you get cramping or pain on either side of your mid-to-lower back? yes no Do you or did you ever have nephritis? yes no Do you or did you ever have cystitis? Yes No Lungs yes no Do you get or have (or have had) bronchitis? yes no Do you get or have (or have had) emphysema? yes no Do you get or have (or have had) asthma? yes no Do you get or have (or have had) C.O.P.D?
  • 7. yes no Are you on inhalers or nebulizers? How often? What type? yes no Do you know what your oxygen saturation is ________? yes no Do you get pain when you breathe? yes no Do you get pain when you take a deep breath? yes no Did you ever or do you have lung cancer? Yes No Lungs (Continued) yes no Do you have a collapsed lung? yes no Are you a smoker? How often? yes no Have you ever had pneumonia? yes no Have you ever worked around toxic chemicals, in coal mines or around asbestos? yes no Do you cough a lot? yes no Do you get any mucus when you cough? yes no What color is the mucus? Other (What are your main health complaints or concerns?) Please list and elaborate on any conditions or symptoms that this questionnaire has not covered or asked you. Past Surgeries Please list any past surgeries you have had (e.g. tonsils removed, hysterectomies, open heart surgery, etc.) Surgery Year
  • 8. Chemical Medications Please list any chemical medications that you are presently taking: Medication Reason: Natural Supplements Please list any natural supplements you are currently taking: Supplements Vitamins & Minerals Allergies Please list anything that you are allergic to: Allergy Genetic History Mom: Dad: (Maternal) Grandfather:
  • 9. (Maternal) Grandmother: (Fraternal) Grandfather: (Fraternal) Grandmother: Sister: Sister: Brother: Brother: J Thank You J