Health Questionnaire

Welcome

This questionnaire will help you determine if you should get help for certain symptoms you may be experiencing.

Each question will present example symptoms for a specific area, and you will rate your symptoms based on your typical health profile for the Past 30 Days. The rating options will be a combination of frequency & severity

The survey should take less than 5 minutes of your time.

*You will need to have Javascript enabled for this questionnaire.

Head

  • Faintness, Headaches, Dizziness






Eyes

  • Itchy, Watery, Yellowing, or Reddened eyes
  • Swollen, Reddened, or Sticky eyelids
  • Bags, Dark Circles
  • Problems with Night Vision, Peripheral Vision, or Blurriness.






Ears

  • Itchy Ears
  • Earaches, Infections
  • Drainage
  • Ringing, Hearing Loss






Nose

Sinus Problems, Stuffy, Excessive Mucus, Hay Fever, Sneezing Attacks, Loss of sense of smell.






Mouth/Throat

  • Chronic Cough, Sore Throat, Hoarseness
  • Gagging/throat clearing
  • Swollen/discolored tongue
  • Coating on tongue, Burning
  • Chewing, or Swallowing problems
  • Canker Sores, Fever Blisters
  • Cracked lips






Hair

  • Thinning, or Loss
  • Loss of outer eyebrow hair
  • Premature greying
  • Easy hair pluckability






Skin

  • Acne, Hives, Rashes
  • Dry skin, Bumps, Flushing
  • Excessive Sweating






Nails

  • Spoon shaped, Brittle, Cracking
  • Discolored, or White Spots, Lines/Stripes






Immune

  • Colds, Flu, Chronic Infections






Heart

  • Irregular/skipped beats
  • Rapid/pounding beats
  • Chest Pain






Lungs

  • Chest congestion
  • Asthma or Bronchitis
  • Shortness of breath
  • Difficulty breathing






Energy/Sleep

  • Fatigue, Lethargy
  • Hyperactivity, Insomnia
  • Sleep disruptions






Digestive Tract/Gastrointestinal (GI)

  • Nausea, Vomiting
  • Diarrhea, Constipation
  • Bloating, Belching
  • Gas/Flatulence
  • Heartburn
  • Upper GI Pain, Lower Abdominal Pain






Joint/Muscle/Bone

  • Arthritis
  • Stiffness/Limited movement
  • Pains or aches in muscles
  • Feelings weakness, or Loss of strength
  • Restless legs
  • Bone Pain, or Broken Bones






Weight

  • Under, or Over weight. Obesity.
  • Weight Loss or Gain (>5-10lbs)
  • Fluid retention






Genitourinary

  • Frequent, or urgent urination
  • Itching
  • Discharge
  • Incontinence






Neurological

  • Pain or Aches in joints
  • Poor Concentration/Brain fog
  • Poor Memory, or Confusion
  • Poor Physical Coordination, Loss of Balance
  • Tingling in hands or feet
  • Stuttering, Stammering, or Slurred speech.






Emotions

  • Mood swings
  • Anxiety, Worry, Fear, Nervousness
  • Anger, Iffitability, Agitaiton
  • Depression






Results

Your total score is

Overall your symptoms are

Get in touch today to reduce your symptoms: