Questionnaire - Page 1 of 9 (1015 maximum possible questions)

Last updated: Dec 08, 2008

PERSONAL BACKGROUND
1.	Do you have any knowledge of diseases/conditions that your parents, grandparents, brothers or sisters have had? Answer 'no' if, for example, you were adopted.	No, I can't answer questions about close relatives Yes, I can answer questions about close relatives More questions later...
2.	Has there been cancer of any type in close family members?	Don't know No Possibly Yes    More questions later...
3.	Are you currently seeing a doctor about your health concerns?	No Medical doctor (MD, DO) Licensed alternative doctor (ND, DC, OMD etc.) Unlicensed alternative practitioner Both Medical and Alternative doctor(s)
4.	Are you currently receiving spinal manipulation (adjustments) from a Chiropracter, Osteopath or other doctor?	Don't know No, I am not No, but have in past, but was not helped No, but have in past, and was helped Yes
5.	Do you routinely get full body massages?	Don't know No / rarely Perhaps once a month or more Once a week More than once a week
6.	What is your ethnic background? (Various conditions affect certain groups more than others)	Other / don't know African descent Asian Caucasian (white) Latin / Hispanic
7.	Ethnic background continued.	Other / don't know Japanese Chinese American Indian East Indian
8.	Have you changed jobs, lost a job or started a new job within the past 2 years?	No / over 2 years ago / don't know Within the past 1-2 years Within the past year Within the past 6 months Within the past 3 months
9.	What is your marital status?	Not applicable / don't know Single Divorced Remarried Married
10.	What is your marital status (continued)?	Not applicable / don't know Engaged Partner died / Widow - Widower
11.	What is the status of your relationship with the person you are married to or living with?	Not applicable / don't know Very troubled Unstable Stable but really needs improvement Stable and good
12.	Have you divorced within the past 2 years?	No / over 2 years ago / don't know Within the past 1-2 years Within the past year Within the past 6 months Within the past 3 months
13.	How many hours do you work each week? 'Work' is defined as tasks which, given the choice, you would rather not do - this can include childcare, housework, studying and so on.	I don't work / don't know Under 35 35 to 47 48-60 Over 60
14.	How would you rate your frequency of vacations? A vacation is a time (usually more than a week) when you relax instead of working or studying, and usually, but not necessarily, in a different setting.	Don't know I need to get away / badly need I probably should take one Haven't had one for ages, but don't feel the need Vacation frequency is good
15.	Within the past 3 years, have you become sick as a result of being in a country where the food or water is known to be unsafe?	Don't know No Yes
16.	Have you served in the military in the Persian Gulf AND experienced health problems that may be due to Gulf War Illness (GWI)?	Don't know No Yes, I served there and suspect a connection Yes, this is a definite possibility I have been diagnosed with GWI
17.	Have you been infected with any form of parasite during the last 2 years? This includes worms, protozoa (such as Giardia or malaria), intracellular parasite (toxoplasmosis) and amoeba, but not yeast (such as Candida), bacteria, or viruses.	Don't know No Yes    More questions later...
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CHILDHOOD
18.	Did you have chicken pox?	Don't know Definitely not Yes
19.	Did you ever get mumps?	Don't know No Yes, no complications Yes, with complications Yes, with testicular swelling
20.	Did you have rheumatic fever?	Don't know No It was suspected Yes, mild case Yes, more serious / more than once
21.	Did you have allergies or signs of allergy such as an "allergic crease" across the nose, runny nose or bags under the eyes?	No / don't know Yes, but insignificant Yes, a few minor ones Yes, one or two severe Yes, several severe
22.	Did you experience growing pains?	No / don't know Minor Moderate Serious Severe
23.	Have you suffered from Osgood-Schlatter Disease (growing pains at the knee)?	No / don't know Mildly in past Significantly in the past Currently mildly Currently significantly
24.	Did you have Osteochondrosis or Leg-Hip Perthes Disease?	No / don't know Yes, but good recovery Severely - lasting skeletal damage
25.	What was your weight, on average, from childhood and into your teens?	Very underweight Underweight Normal / don't know Overweight Very overweight
26.	Was your hair sensitive to brushing or combing (pulling, manipulation), or was it painful to remove something from your hair?	No / don't know Yes
27.	Did your head sweat easily or at night?	No / don't know Yes
28.	Did you roll your head on the mattress, or tend to rock back and forth?	No / don't know Yes
29.	Were you inappropriately physically punished / abused as a child? Do not include sexual abuse here.	No / don't know Mildly - an occasional smack Moderately - regular light physical punishment Occasional severe physical punishment/abuse Severely - frequent hard physical punishment/abuse
30.	Were you ever molested / sexually abused / raped as a child? Only include incidents that occurred up until the age of 18.	No / can't remember / don't know There was occasional molestation Frequent molestation and/or isolated serious abuse Occasional serious abuse over a long period Frequent serious abuse over a long period
31.	Did your legs get tired easily; did you want to be carried a lot?	Don't know No Yes
32.	Were you a hyperactive child?	No / don't know Somewhat - I was more active than most children Definitely - I was a 'real handful' Severely - I was out of control
33.	Have you had most or all of the 'required' vaccinations?	No / don't know Yes
34.	At what age was puberty onset, based on first physical signs (usually pubic hair development)?	10 or younger 11 12 / don't know 13 14 or older
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SYMPTOMS: GENERAL
35.	Bodily coordination. How good is your control over your physical movements, for example picking up something very small or catching a ball?	Very poor - I'm very clumsy / drop things Probably worse than average Average / don't know Better than average Excellent
36.	Have you had neuritis (inflammation of nerves) or a neuropathy (a condition of nerve degeneration)?	Never had it / don't know Probably had it / minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
37.	Do you ever feel dizzy / faint when standing / sitting up suddenly?	Don't know Never / very rarely Occasionally - several times per year Often - several times per month Always or almost always
38.	Do you ever feel dizzy or faint for reasons unrelated to standing or sitting up suddenly?	Don't know Never / very rarely Occasionally - several times per year Often - several times per month Always or almost always
39.	Do you have fainting episodes where you actually lose consciousness or fall to the floor?	Don't know No In the distant past only Occasionally Frequently
40.	Do you ever experience vertigo?	Don't know Never / very rarely Occasionally - several times per year Often - several times per month Daily or almost daily
41.	Do your hands and / or feet tend to be...?	Usually cold Sometimes cold Normal / don't know Sometimes warm Usually warm
42.	How well do you tolerate other people?	I am not critical; I tolerate / forgive easily I occasionally have difficulty tolerating people I'd say I'm about average / don't know I am sometimes over-critical I tend to be critical, unforgiving, quick to judge
43.	What is your level of pain tolerance generally?	Very poor pain tolerance Poor pain tolerance Average / don't know Moderate pain tolerance High pain tolerance
44.	Do you have a sense of humor?	Very little / none Somewhat I'd say I'm about average / don't know More than average Over the top
45.	Inflammation. Have you suffered from one or more inflammations that seem chronic or recurring?	No / don't know Minor, for one condition Minor, for more than one condition Major, for one condition Major, for more than one condition
46.	How easy do you find it to relax?	Very difficult Mildly difficult Average / don't know Fairly easy I am very relaxed by nature
47.	Do you tend to recover slowly from colds and / or feel weak afterwards?	Don't know No, I generally recover fully within a day or two Sometimes Often Always
48.	Do you have a sensation of general weakness?	No / don't know Mild, sometimes present Moderate Serious Severe, always present
49.	Activity. Are your physical motions...?	Slow / heavy Average / don't know Quick / efficient / light
50.	Have you had a problem with fatigue, becoming too easily exhausted, or poor recover after exercise?	Don't know No, never Yes, in the past only Yes, it is a current or ongoing problem More questions later...
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SYMPTOMS: AGING
51.	Do you have brown 'age spots' on your skin? Also known as 'liver spots', these are larger than and different from freckles.	No / don't know One or two Fewer than 10 10 or more, but not increasing in number 10 or more and increasing
52.	Skin Elasticity. Pinch a large section of skin on the back of your hand, holding firmly for 5 seconds. Release and count the number of seconds for the pinched skin to return to its normal (totally flat - don't cheat!) appearance.	No / don't know 0-2 seconds (very elastic) 3-4 seconds 5-8 seconds Over 8 seconds (very inelastic)
53.	Balance. Stand on a hard surface with feet together. Close your eyes and lift your dominant foot about six inches (15cm). How long can you stand on your other foot without falling or opening your eyes? For better accuracy, do this 3 times and average.	I can't do this test / I am injured / don't know Under 4 seconds (poor balance) 4-9 seconds 10-25 seconds Over 25 seconds (very good balance)
54.	Are you concerned about wrinkles in your skin?	No / don't know Moderately Very
55.	Does your health seem to be declining as you age?	No more than normal / don't know No, not at all Slightly - minor issues are turning up Moderately - I am definitely having more problems Seriously - my health is declining at a rapid rate
56.	Have you had a stroke-type event?	No / don't know Diagnosed VBATD or carotid occlusion only One or more TIAs (mini-strokes) An actual stroke A severe stroke or more than one
57.	Do you have an overall loss of interest or pleasure in activities that you once enjoyed?	Don't know No Slightly Moderately Completely or almost completely
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SYMPTOMS: FOOD: GENERAL
58.	Do you need to get up and eat during your hours of sleep?	No / don't know Rarely - less than once per month I eat a little occasionally, less than once a week I eat a lot occasionally or a little regularly I eat a lot regularly, several times per week
59.	Do you make a point of avoiding aspartame? It is commonly found in low-calorie drinks and foods.	No / don't know Sometimes I generally try to avoid it I try very hard to avoid it I absolutely avoid it
60.	Do you have any adverse reaction when consuming aspartame, the artificial sweetener?	Don't know No, defintely not Mildly / probably Moderate Severe
61.	Do you use the artificial sweetener Sucralose (Splenda)?	Don't know No, I avoid it Yes, I occasionally use it Moderately Use it at least once a day
62.	Are you bothered by eating food containing monosodium glutamate (MSG)? Typical reactions might include headaches, double vision, diarrhea or dizziness.	Don't know Definitely not Mildly Moderately Severely
63.	Are you lactose intolerant?	Don't know No, I know I am not Moderately, resolved by lactase / consuming less Severe problem and must strictly avoid dairy
64.	How often do you need to eat each day to maximize your well-being and productivity?	Under three meals with no/light snacks Three meals with no snacks Three meals and occasional snacks / don't know Three meals with consistent snacking At least three meals and large snacks
65.	Is your appetite generally...?	Very weak - I eat infrequently and small amounts Weak Average / don't know Strong Very strong - I rarely miss an opportunity to eat
66.	Have you lost your appetite suddenly within the past month?	Don't know No Yes, but it has now returned Yes, 2-4 weeks ago and it has not returned Yes, under 2 weeks ago and it has not returned
67.	How often do you diet?	Never / don't know Sometimes, in the past only Often, in the past only Once or twice in the past year More than twice in the past year
68.	Have you experienced the eating disorder known as anorexia?	Don't know No In the past only, not a current problem Current moderate problem Current major problem
69.	Have you experienced the eating disorder known as bulimia?	Don't know No In the past only, not a current problem Current moderate problem Current major problem
70.	Is your stomach upset by greasy food?	No / don't know Mildly Moderately Seriously Severely
71.	Do you experience diahrrea from eating large amounts of fat or oil?	Don't know No Mildly Moderately Severely
72.	Do you have any digestive problem when eating garlic or onions?	Don't know No Yes, trouble with garlic Yes, trouble with onions Trouble with both
73.	How well do you chew your food?	Hardly chew at all Less than I probably should About average / don't know Am pretty good about it Very thoroughly
74.	Do you find that you need to observe "food combining" rules. Such rules generally include protein separated from starch and fruit, liquids alone, fruits alone and melons alone.	Uncertain / don't know No, can digest any combination Sometimes / somewhat Most of the time Always, or I don't do well
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