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 Family Chiropractic Wellness & Holistic Healthcare Center

 

Wellness Questionaire

 

The purpose of this questionnaire is to comprehensively evaluate each of your body's organ system over the last six months.  Responses are compared against the e-Wellness Systems database, summarized and forwarded to our health center for evaluation.  Once survey is submitted please contact the office to schedule an appointment to review the information and recommendations based on the survey results.  In some cases additional information may be requested to further evaluate a particular system of the body.

(* = required field) 
First Name*
Middle Name
Last Name*
Email*


Instructions: 

Answer the following questions as best you can. If applicable, answers should reflect symptoms or events experienced

within the last six months.

 

  Response Meaning Mark When...
  A Always or Yes Symptom or Event is persistent
  F Frequent Symptom or Event is Frequent or Common
  R Not Applicable or No Symptom or Event is Rare or Uncommon
  N/A Not Applicable or No or Never Default selection


1 N/A R F A Consume breads / pastas / starches
2 N/A R F A Yeast / Fungal problems
3 N/A R F A Tickle in your throat
4 N/A R F A Cough / spit clear sputum / phlegm
5 N/A R F A Unexplained weight loss
6 N/A R F A Nervousness or irritable
7 N/A R F A Thinning of skin
8 N/A R F A Prostate problems
9 N/A R F A A family history of diabetes
10 N/A R F A A family history of cancer
11 N/A R F A A family history of heart disease
12 N/A R F A Alcohol socially
13 N/A R F A Alcohol use extensivily
14 N/A R F A Do you use street drugs
15 N/A R F A Drink coffee / soda / ice tea
16 N/A R F A Smoke or use tobacco
17 N/A R F A Eat fast food
18 N/A R F A Eat pre processed / packaged foods
19 N/A R F A Consume sweets
20 N/A R F A Use artificial sweetners
21 N/A R F A Drink cow's milk
22 N/A R F A Consume white sugar
23 N/A R F A Consume refined carbs
24 N/A R F A Consume wheat or gluten
25 N/A R F A Consume artificial flavorings
26 N/A R F A Very little exercise
27 N/A R F A Family or financial stressors
28 N/A R F A Rashes
29 N/A R F A Rosacea
30 N/A R F A Itchy or dry skin
31 N/A R F A Oily skin
32 N/A R F A Acne
33 N/A R F A Eczema
34 N/A R F A Psoriasis
35 N/A R F A skin cancer
36 N/A R F A Vertigo / dizziness
37 N/A R F A Light headedness
38 N/A R F A Glaucoma
39 N/A R F A Cataracts
40 N/A R F A Double vision or blurred vision
41 N/A R F A Dry or red eyes
42 N/A R F A Macular degeneration
43 N/A R F A Watery eyes
44 N/A R F A Itchy eyes
45 N/A R F A Pufffy eyes
46 N/A R F A Ear infections
47 N/A R F A Tooth cavities
48 N/A R F A Bad breath
49 N/A R F A Runny nose / sneezing
50 N/A R F A COPD / lung disease
51 N/A R F A emphysema
52 N/A R F A chronic bronchitis
53 N/A R F A Difficulty breathing deeply
54 N/A R F A Acute or chronic coughing
55 N/A R F A Wheezing with breathing
56 N/A R F A Asthma
57 N/A R F A Shortness of breath
58 N/A R F A Pain when taking a breath
59 N/A R F A Difficulty going to sleeping
60 N/A R F A Difficulty staying asleep
61 N/A R F A Hungry all the time
62 N/A R F A Can't lose weight
63 N/A R F A Can't gain weight
64 N/A R F A Slow metabolism
65 N/A R F A Overweight
66 N/A R F A Gout
67 N/A R F A Diabetes
68 N/A R F A Metabolic syndrome
69 N/A R F A Thyroid problems
70 N/A R F A Too much stress / tension
71 N/A R F A Heat / cold intolerance
72 N/A R F A Cough / spit green-yellowish sputum / phlegm
73 N/A R F A Trouble with edema / swelling
74 N/A R F A Early aging
75 N/A R F A Trouble sweating
76 N/A R F A Fatigued or tired
77 N/A R F A Unexplained swellings
78 N/A R F A Diabetic medications
79 N/A R F A Thyroid medication
80 N/A R F A Diuretics
81 N/A R F A Erectile dysfunction
82 N/A R F A Pre-menopausal
83 N/A R F A Peri-menopausal
84 N/A R F A Suffer from PMS
85 N/A R F A Breast tenderness
86 N/A R F A Vaginal discharge
87 N/A R F A Vaginal dryness
88 N/A R F A Birth control
89 N/A R F A Irregular periods
90 N/A R F A Excessive period bleeding
91 N/A R F A Athlete's Foot
92 N/A R F A Ovarian cysts
93 N/A R F A Fibrocystic breasts
94 N/A R F A Fertility concerns
95 N/A R F A Increase in urination
96 N/A R F A Pelvic pain or cramping
97 N/A R F A Mood swings
98 N/A R F A Bouts of depression
99 N/A R F A Manic episodes
100 N/A R F A Loosing your memory
101 N/A R F A Hot flashes / sweats
102 N/A R F A Thinning hair or brittle hair
103 N/A R F A Sexually transmitted diseases
104 N/A R F A Decrease in sex drive
105 N/A R F A Pain with sex
106 N/A R F A Hormone replacement
107 N/A R F A Heart medication
108 N/A R F A a heart attack
109 N/A R F A heart surgery
110 N/A R F A Chest pain / angina / tightness
111 N/A R F A High blood pressure
112 N/A R F A A-fib or arrhythmias
113 N/A R F A heart problems
114 N/A R F A Slow or fast heart beats at rest
115 N/A R F A deep vein thrombosis
116 N/A R F A Poor circulation in your hands
117 N/A R F A Poor circulation in your feet
118 N/A R F A Concerns about a stroke
119 N/A R F A Restless leg syndrome
120 N/A R F A Bruise easily
121 N/A R F A Heart burn or reflux
122 N/A R F A Upset stomach
123 N/A R F A Belching
124 N/A R F A Ulcers
125 N/A R F A Pain after eating
126 N/A R F A Heartburn medication
127 N/A R F A Indigestion or bloating
128 N/A R F A Abdominal cramps or pain
129 N/A R F A Irritable bowel syndrome
130 N/A R F A Diarrhea
131 N/A R F A Inflammed intestine - "Leaky gut"
132 N/A R F A Dark black / tarry stools
133 N/A R F A Blood streaked stools
134 N/A R F A Blood on the toilet paper
135 N/A R F A Crohn's Disease
136 N/A R F A Ulcerative colitis
137 N/A R F A Colon polyps
138 N/A R F A Diverticulitis
139 N/A R F A Constipation
140 N/A R F A Laxitives
141 N/A R F A urinary tract infections
142 N/A R F A kidney stones
143 N/A R F A Blood in your urine
144 N/A R F A Bed wetting
145 N/A R F A Urinary discharge (abnormal)
146 N/A R F A Dark or smelly urine
147 N/A R F A Over-active bladder
148 N/A R F A Urinary urgency
149 N/A R F A Urinary hessitancy
150 N/A R F A Headaches or migraines
151 N/A R F A Stiffness or muscle spasms
152 N/A R F A Bone pains
153 N/A R F A Difficulty exercising
154 N/A R F A Fibromyalgia
155 N/A R F A Chronic fatigue syndrome
156 N/A R F A Back pain or neck pain
157 N/A R F A Joint pain
158 N/A R F A Arthritis
159 N/A R F A Rheumatoid arthritis
160 N/A R F A Muscle weakness
161 N/A R F A Osteoporosis
162 N/A R F A Muscle relaxors
163 N/A R F A seizures
164 N/A R F A Anti-depressants
165 N/A R F A Pain medications
166 N/A R F A Multiple sclerosis
167 N/A R F A Numbness or tingling
168 N/A R F A Poor coordination
169 N/A R F A ADHD / ADD learning disorders
170 N/A R F A Brain fog - lack of concentration
171 N/A R F A Anxiety / anxiousness
172 N/A R F A Problems relaxing
173 N/A R F A Feelings of worthlessness
174 N/A R F A Allergies
175 N/A R F A Sick more often
176 N/A R F A Swollen glands
177 N/A R F A Recently taken antibiotics
178 N/A R F A Scleroderma or Sjogrens disease
179 N/A R F A Fever blisters or cold sores
180 N/A R F A Warts
181 N/A R F A Sore Throat
182 N/A R F A Cholesterol problems
183 N/A R F A Cholesterol medication
184 N/A R F A Gall bladder attacks
  

Thank you for Submitting your Questionnaire!

For a professional assessment of the results, please contact your doctor to make an appointment.

 

 

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Page Last Modified: December 15, 2006