Take a minute to fill up the following forms & answer the questions . Demographic (form 1)Health Behavior & timelines (form 2 )Gut Health & Mold Questions ( form 3)Medical Symptoms Questionnaire (MSQ) Please fill in the data below: Demographicform 1 Name * First Name Last Name Date of birth * MM DD YYYY Gender * Male Female Weight * Height * Marital status * Married Single Separated/Divorced Widow Number of children * Occupation * Smoking history * Never Current Past Type of smoking * Years of smoking and amount * Alcohol * No Yes Other substances use * No Yes Specify * Medications list List all of your medications with their dosages and start and end dates Supplements list: * List all of your supplements with the dosages , start and end dates Phone * Country (###) ### #### Email * Thank you for submitting form 1. Please proceed to form 2 Health Behavior &Timelines (form 2) Name First Name Last Name 1. Are you currently taking insulin? * YES NO 2. Are you currently taking Coumadin? * YES NO 3. Do you have kidney stones? * YES NO 4. Family Health: Write down any family members—children, parents, siblings, aunts, uncles, grandparents, first degree cousins—who have had any of the following health issues: Brain or mental health issues Heart issues Autoimmune issues 5. Parental health: Health of your mother prior to pregnancy: * GOOD POOR UNKNOWN SMOKER Parental health:Health of your father prior to pregnancy: * GOOD POOR UNKNOWN SMOKER 6. Birth circumstances: * Vaginal birth Cesarean Section Unknown if vaginal or cesarean Premature or stressful birth Time spent in neonatal intensive care unit after birth Antibiotics at birth or shortly thereafter Breastfed NEVER YES 7. Age of first antibiotic (approximate) * Antibiotic exposure: How often have you taken antibiotics in your lifetime? * Less than 5 courses 5-10 courses 11-20 courses Greater than 20 courses 8. Toxin Exposure: Private well Industrial solvents Agricultural Water damaged buildings Mold Art/hobby Welding Other 9. Infections: Lyme disease Infectious mononucleosis Other 10. Stress: Write down how old you were when you were affected by any of the following events. If the event occurred multiple times, write down your age at each occurrence. * Divorce Work conflict Trauma Family conflict Death of friend/family Other 11. How old were you when you last felt well: * 12. Current concerns: (List up to 5: pain, balance, mood, etc.) 13. Major milestones. List up to 5 milestones of onset of new symptom or worsening symptoms related to your current concerns: * 14. Known food or drug allergies 15. Sleep: How many hours of sleep do you get every night? * Describe your quality of sleep: GOOD FAIR POOR 16. Exercise/movement: How often do you exercise?Times/week Minutes/session Type of Exercise(s) 17. Diet: Circle those that you have, or currently are eating: Vegetarian Vegan Diabetic Atkins Paleo Ketogenic Standard American Diet (SAD) Other 18. Stress-reducing practices: * Meditation Mindfulness Yoga or Tai Chi Gardening Time in nature Journaling Epsom Salt / dead sea salt soaks Massage Prayer Other How many minutes per day on average * How many sessions per week on average * 19. Life purpose: Do you have a clear personal mission? YES NO Do you have supportive individuals in your life? * YES NO Do you have a group that is emotionally supportive? * YES NO Is your self-talk mostly positive? * YES NO Is your spiritual life satisfactory? * YES NO 20. Digestion: Check medications you are taking now or have taken in the past: * Acid lowering medication NSAIDs Hormones Antibiotics Prednisone History of bloating? YES NO History of Constipation? YES NO History of Diarrhea? * YES NO Probable dysbiosis? * YES NO 21. Immune cells protecting / attacking: Infection history? * YES NO Autoimmune diagnosis? * YES NO Other 22. Energy (Mitochondria): Check the symptoms that are presently a problem: * Fatigue Chronic headache Heart failure Worsening memory Macular degeneration Retinal problem 23.Hormones: Check the symptoms that are presently a problem: * Chronic severe stress Probable low Vitamin D Infertility Endometriosis Pelvic pain Chronic prednisone use Erectile dysfunction Low libido Thyroid hormone problem Other 24. Dental Health Do you have amalgam fillings * YES NO Age of first filling? How many total? Did you have them removed? YES NO Was this with a Dentist wearing protective gear and using a respiration system? YES NO Do you have any root canals? * YES NO How many? 25. Trauma: Check the symptoms that are presently a problem: Are you currently suffering from (check all that apply): Injury to head Injury to neck or spine Chronic severe pain Concussion Loss of consciousness Car or motorcycle accident Fall Seeing stars Sports injury 26. Major environmental factors likely contributing to current health problems. Check all that apply: * Genetic inefficient enzymes for handling B vitamins and processing toxins (family history of brain, heart, autoimmune issues) Toxic relationships (people or habits that sabotage your efforts to improve health) Antibiotic and/or medication use that causes problems with gut bacteria (dysbiosis) Unrecognized food sensitivities (gluten, dairy) Toxin exposures and inefficient enzymes Mitochondrial strain Hormone problems Chronic elevation of stress hormones Poor resilience factors (support, self-talk, spiritual life, meaning) Poor health Poor health behaviors (poor sleep, little exercise, poor diet, no stress-reducing practices) Prior head injury Other Prior head injury Other Thank you! for submitting form 2.Please proceed to form 3 Questionnaire for: SIBO, Intestinal Yeast Overgrowth, Parasites & Leaky GutForm 3 Name * First Name Last Name SIBO: Check every box that applies to you: * I have been diagnosed with hypothyroidism – either Hashimoto’s or non-autoimmune. I have been diagnosed with irritable bowel syndrome or inflammatory bowel disease. I get bloated after meals or feel bloated a lot of the time. I have gas, abdominal pain, or cramping I have odorous, loose stools. I have food intolerances, such as gluten, dairy, soy, or corn. I have histamine intolerance. My joints ache I feel tired all the time. I have skin issues, such as eczema, psoriasis, hives, rosacea, or an unexplained rash. I have asthma or other respiratory problems I feel depressed and hopeless. I have been diagnosed with a vitamin B12 deficiency. Yeast Overgrowth: Check every box that applies to you: * I have an autoimmune disease, such as Hashimoto’s thyroiditis , Graves’ disease, rheumatoid arthritis, ulcerative colitis, lupus, psoriasis, scleroderma, or multiple sclerosis. I have skin or nail fungal infections, such as athlete’s foot, ringworm, or toenail fungus. I suffer from chronic fatigue or fibromyalgia, or I am tired all the time. I have digestive issue, such as bloating, constipation, or diarrhea. I have difficulty concentrating, poor memory, lack of focus, ADD,ADHD, or brain fog. I have skin issue, such as eczema, psoriasis , hives, rosacea, or an unexplained rash. I am easily irritated and/or have frequent mood swings, anxiety, or depression. I get vaginal yeast infections, having rectal itching , or have vaginal itching. I suffer from seasonal allergies or itchy ears. I have craving for sugar and refined carbohydrate Parasites: Check every box that applies to you: * I have been diagnosed with hypothyroidism – either Hashimoto’s or non-autoimmune. I have constipation, diarrhea, or gas I have traveled internationally I remember getting traveler’s diarrhea while outside the country. I have had what I believe was food poisoning and my digestion has not been the same since. I have trouble falling asleep and I wake up multiple times during the night. I have skin issues such as eczema, psoriasis, hives, rosacea, or an explained rash. I grind my teeth in my sleep. I have pain or aching in my muscles or joints. I feel exhausted, depressed, or apathetic almost all the time. I never feel satisfied after I eat. I have iron-deficiency anemia. I have been diagnosed with irritable bowel syndrome, ulcerative colitis , or Crohn’s disease Leaky gut: Check every box that applies to you. Digestion: * I see undigested food in my stool I have gas and /or bloating after eating meals. I have reflux, burning in my chest, or burping after meals. My stomach feels heavy after eating. I do not have at least one bowel movement a day. I have frequent loose stools. My stools are small and poorly formed or they are very hard. Leaky gut: Check every box that applies to you. Heath: * I have food sensitivities or intolerances I have an autoimmune disease, such as Hashimoto’s thyroiditis , or Graves’ disease. I am under chronic stress. I have trouble getting 7 ½ to 9 hours of good-quality sleep. I have yeast overgrowth or SIBO ( no need to answer this one) MOLD Symptoms: Do you have the following symptoms? * Fatigue Weakness General achiness Unusual pain that a cause has been undetermined Ice pick pain or lightning bolt sensations Joint pain Muscle cramps Buzzing or tremor sensation in the body Headaches Numbness or tingling Light sensitivity Skin sensitivity Red eyes Blurred vision Frequent sinus infections Sinus congestion Productive cough Shortness of breath Excessive thirst Inability to lose weight Intense anxiety and/or depression Poor memory or poor word recall Difficulty focusing or concentrating Dizziness Abdominal pain Diarrhea Night sweats MOLD Exposure: Have you had any of the following in your current or past residence? * Roof leaks? Window leaks? Broken water pipes? Any water stains on ceilings or walls? Any rooms in the home that smell musty? Do you suspect that your home has or had mold in it? Is any amount of mold visible around the shower/tub or sinks in your home? Have you worked in an older building or known of water damage or mold to be present? Thank you! for submitting form 3.Please proceed to MSQ form Medical Symptoms Questionnaire (MSQ)Rate each of the following symptoms based upon your typical health profile for the past 14 days .Point scale:0-Never or almost never have the symptoms1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 -Frequently have it, effect is not severe4 - Frequently have it, effect is severe Name * First Name Last Name Have you experienced any of the following neurological symptoms in the last 14 days? SELECT ALL THAT APPLY Headaches * Faintness * Dizziness * Insomnia * Have you experienced any of the following eyes symptoms in the last 14 days? SELECT ALL THAT APPLY Watery or itchy eyes * Swollen, reddened or sticky eyelids * Bags or dark circles under eyes * Blurred or tunnel vision (Does not include near or far-sightedness) * Have you experienced any of the following ears symptoms in the last 14 days? SELECT ALL THAT APPLY Itchy ears * Earaches, ear infections * Drainage from ear * Ringing in ears, hearing loss * Have you experienced any of the following nose symptoms in the last 14 days? Stuffy nose * Sinus problems * Hay fever * Sneezing attacks * Excessive mucus formation * Have you experienced any of the following mouth/throat symptoms in the last 14 days? Chronic coughing * Gagging, frequent need to clear throat * Swollen or discolored tongue, gums, lips * Sore throat, hoarseness, loss of voice * Canker sores * Have you experienced any of the following skin symptoms in the last 14 days? SELECT ALL THAT APPLY Acne * Hair loss * Hives, rashes, dry skin * Flushing, hot flashes * Excessive sweating * Have you experienced any of the following cardiac symptoms in the last 14 days? SELECT ALL THAT APPLY Rapid or pounding heartbeat * Irregular or skipped heartbeat * Chest pain * Have you experienced any of the following respiratory symptoms in the last 14 days? SELECT ALL THAT APPLY Chest congestion * Asthma, bronchitis * Shortness of breath * Difficulty breathing * Have you experienced any of the following gastrointestinal symptoms in the last 14 days? SELECT ALL THAT APPLY Nausea or vomiting * Diarrhea * Constipation * Bloating feeling * Belching , passing gas * Heartburn * Intestinal/ stomach pain * Have you experienced any of the following musculoskeletal symptoms in the last 14 days? SELECT ALL THAT APPLY Pain or aches in joints * Arthritis * Stiffness or limitation of movement * Pain or aches in muscles * Feeling of weakness or tiredness * Have you experienced any of the following weight systems in the last 14 days? SELECT ALL THAT APPLY Bing eating/drinking * Craving certain foods * Excessive weight * Compulsive eating * Water retention * Underweight * Have you experienced any of the following energy/activity symptoms in the last 14 days? SELECT ALL THAT APPLY Fatigue , sluggishness * Apathy, lethargy * Hyperactivity * Restlessness * Have you experienced any of the following mental symptoms in the last 14 days? SELECT ALL THAT APPLY Poor memory * Confusion, poor comprehension * Poor concentration * Poor physical coordination * Difficulty in making decisions * Stuttering or stammering * Slurred speech Learning disabilities * Have you experienced any of the following emotional symptoms in the last 14 days? SELECT ALL THAT APPLY Anxiety, fear, nervousness * Mood swings * Anger, irritability, aggressiveness * Depression * Have you experienced any of the following in the last 14 days? SELECT ALL THAT APPLY Frequent illness * Frequent or urgent urination * Genital itch or discharge * Thank you!
