Questionnaire - Page 3 of 9 (1015 maximum possible questions)

Last updated: Dec 08, 2008

SYMPTOMS: MUSCULAR
205.	Tendonitis	Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current severe problem
206.	For someone of your age and sex, is your muscular strength...?	Very poor Poor Average / don't know Great Very great
207.	How is your muscle tone, compared to others of your age?	Very poor (hypotonia) Poor Average / don't know Good Excellent
208.	Do you tend to have a thick musculature, even without working out? Please answer this question as though you were not working out.	No, very light musculature by nature Tends to be light Average / don't know Tends to be thick / heavy Yes, very thick / heavy by nature
209.	Is your reaction time / reflex...?	Very slow/poor Slow/poor Average / don't know Fast/good Very fast/good
210.	Do you have pain between the shoulder blades?	No / don't know Yes, some Yes, significant
211.	Do you experience shoulder pain?	No / don't know One or both hurt, due to an injury Minor problem / comes and goes One hurts most of the time (not related to injury) Both hurt most of the time (not related to injury)
212.	Have you had any problems with your muscles? This includes any muscular disease or specific problem like muscle loss, weakness, pain, spasms, cramping, tremors, tightness, rigidity, soreness, etc., but does not include seizure activity.	Don't know No Yes, I have muscular problems or disease More questions later...
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SYMPTOMS: SKELETAL
213.	Are you shorter than you used to be?	No / don't know Yes, an inch (2.5cm) or less Yes, more than one inch (2.5cm)
214.	How would you or others rate your posture? The shoulders and head are usually hunched forward and the back bent forward in poor posture. Your ears, shoulders, hips, knees, and ankles should make a straight line, when viewed from the side.	Don't know Very poor Poor Average Excellent
215.	Have you had a sideways curvature of the spine called scoliosis?	Don't know No Yes, but corrected now Current minor problem Current major problem
216.	Does / did your breastbone protrude outward (pigeon breast) or inward (funnel chest) more than it should?	Don't know No, positioned normally Pushes / pushed inward Pushes / pushed outward
217.	What is the length of your fingers and toes?	Very short / stubby Short / stubby Average / don't know Long / slender Very long / slender
218.	Are the length of your arms and legs proportional to your torso?	Don''t know Shorter than they should be Average / typical Longer than they should be Much longer than they should be
219.	Is one leg shorter than the other, and not compensated for by the regular use of a heel lift or custom made shoe?	Don't know No, they are of equal length Compensed for with heel lift / raised shoe 1/2 inch or less Greater than 1/2 inch
220.	Have you ever broken any bones?	No / don't know Once Twice Three times Four times or more
221.	Have you ever had any dislocations?	No / don't know Yes, one Yes, more than one
222.	Have you had Bursitis (painful inflammation of joints, usually caused by overuse and/or excess pressure)?	No / don't know Some, in the past Numerous past episodes Current minor problem Current major problem
223.	Have you suffered from Dupuytren's Contracture?	Don’t know No Yes, treated surgically Early signs are present Current problem
224.	Do you suffer from heel pain? Include pain at your heel or slightly forward of the heel on the bottom of your foot.	Don't know No Yes, but I am uncertain of what the cause is Yes, diagnosed as plantar fasciitis Yes, plantar fasciitis with heel spur(s)
225.	What is the condition of the arches of your feet?	Don't know Flat footed / poor arches Average arch Increased arch shape
226.	Does the shape of your face tend to be...?	Very round face/skull Roundish face/skull Average / don't know Slightly angular Very angular/pointed
227.	Are you double-jointed?	No / don't know Somewhat Very
228.	Have you ever had a herniated disc ("slipped disc")?	No / don't know Probably Yes, one minor episode Yes, several minor or one major episode Yes, several major episodes
229.	Do you seem to have relaxed ligaments or loose joints?	No / don't know Yes, somewhat Yes, very
230.	Have you suffered TMJ (Tempero-Mandibular Joint, hinge of the jaw) malfunction involving clicks, pops, locking or noises?	Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem
231.	Do your joints click or pop?	No / don't know One or two, barely noticeably Several, barely noticeably One or two, noticeably (audibly) Several, noticeably (audibly)
232.	Do you suffer from chronic pain from any joint in your body (neck, back, knee, elbow, ankle, etc.) that is associated with a past injury or abuse?	No / don't know Mildly Moderately Seriously Severely - excruciating
233.	Do you suffer from neck pain?	No / don't know Minor problem now resolved Major problem now resolved Current / chronic minor problem Current significant problem
234.	Do you suffer from knee pain?	Don't know No Problem resolved now Current / chronic or minor problem Current significant problem
235.	Do you suffer from lower back pain?	No / rarely / don't know Minor problem now resolved Major problem now resolved Current/chronic minor problem Current/chronic significant problem
236.	Do you suffer from sciatica?	Don't know No In the past only Current minor problem Current significant problem
237.	Do you experience hip pain?	No /don't know In the past only Minor problem / comes and goes Major problem in one hip Major problem in both hips
238.	Do you have pain, stiffness or swelling in any of your joints?	No / don't know Minor in one or two joints Minor in several, or moderate in one or two Major in one or two, or moderate in several Major, in several joints
239.	Have you suffered from sciatica (pain going down one or both legs)?	I never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem
240.	Do you suffer from morning stiffness or stiffness that is generally increased in the morning?	Don't know No Mild / goes away in less than an hour Pronounced / goes away in less than an hour Severe or lasts more than an hour
241.	Do you have any other bone, joint or skeletal problems? This would include osteoporosis, arthritis, joint pain, bone pain, carpal tunnel syndrome, gout, easily broken bones, etc.	Don't know No Yes    More questions later...
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SYMPTOMS: NERVOUS
242.	Do you sometimes have a burning or tingling sensation on your face?	Don't know Never Mild / occasionally Moderate / frequently Severe / constantly
243.	Do you sometimes experience pain on one side of your face?	Don't know No Yes, tends to be a constant pain Moderate shooting type pain Sudden, severe, or lancing pain
244.	Do you suffer from Bell's Palsy (facial muscle droop - one-sided facial paralysis)?	No / don't know Mildly Moderately Seriously Severely
245.	Do you suffer pain on the inside of your knee(s) or on one side of your lower back?	No / don't know Yes, some Yes, severe
246.	Have you suffered injury to your spinal cord?	No / don't know Mild Moderate Serious, including temporary loss of motor control Severe, including permanent paralysis
247.	Do you have numbness, tingling or burning in the extremities (hands, fingers, feet, toes)?	No / don't know Yes, some Yes, significant
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SYMPTOMS: LIVER / GALLBLADDER
248.	Have liver / gallbladder cleanses helped you? Generally these involve drinking olive or other kinds of oil.	Never tried one / don't know No, there was no benefit There was some benefit Moderate benefit Significant benefit
249.	Do you have pain under the right side of your rib cage?	Never / don't know Occasional moderate discomfort Frequent moderate discomfort Occasional severe pain Frequent severe pain
250.	Do you have pain beneath or near your shoulder blade (scapula)?	Don't know No Both shoulder blades Left side only Right side only
251.	Hepatitis A. Have you ever been diagnosed with it?	Never had it / don't know Probably had it/minor episode Major episode, now resolved Current minor problem Current major problem
252.	Have you had any problems with your gallbladder that you know of? This includes having had your gallbladder removed.	Don't know No Yes / probably    More questions later...
253.	Do you have any known problems with your liver? This includes cirrhosis, infection such as hepatitis, enlargement, Gilbert's syndrome, etc…	Don't know No Yes    More questions later...
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SYMPTOMS: GASTRO-INTESTINAL: GENERAL
254.	Do you suffer from belching (burping) within 1 hour of a meal?	Don't know No Occasionally Often
255.	Do you suffer from bloating or digestive disturbances after eating?	Don't know No Occasionally Often
256.	Do you feel as though food remains in your stomach too long? The stomach usually retains food for 3-4 hours before releasing it to the small intestine.	Don't know No Possibly / occasionally Frequently Frequently, confirmed by testing
257.	Have you been diagnosed with rapid gastric emptying? This is also known as gastric dumping or gastric dumping syndrome.	Don't know No, it has been ruled out It has been suggested but not confirmed Occasional confirmed problem Frequent confirmed problem
258.	Have you had a portion of your small bowel removed?	Don't know No Less than 50cm (20 inches) More than 50cm (20 inches)
259.	Do you have difficulty swallowing? This is apart from the pain felt from a simple sore throat.	Don't know No Occasionally / mild Often / severe
260.	Do you suffer from lower bowel gas (flatulence)?	No / 'average' / don't know Moderately Severely
261.	Do you experience motion sickness?	Don't know No Slightly Moderately Severely
262.	Do you suffer from nausea that is not part of a known condition, like motion sickness, pregnancy and gallbladder disease?	Never / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
263.	Do you suffer from vomiting that is not part of a known condition such as food poisoning?	Never / don't know Occasionally Often - several times per week
264.	Is your stomach upset by taking supplement tablets?	No / don't know Yes
265.	Does your anus itch?	Never / don't know Occasionally Often, mostly at night Often
266.	Do you have a rectal discharge of mucous or pus. This does not include fresh blood.	Don't know No Slight Significant Significant with blood
267.	Have you experienced any form of abdominal or groin pain, discomfort or bloating within the past 3 months? This includes upper abdominal pain such as experienced in heartburn or ulcers.	Don't know No Yes, but fully resolved now Yes    More questions later...
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SYMPTOMS: GASTRO-INTESTINAL: CONDITIONS This section asks specifically about conditions that you are already aware of. If you are unsure of an answer, leave it as "don't know" - you will be asked about individual symptoms elsewhere.
268.	Have you had a problem with hemorrhoids?	Never had one / don't know Probably had one/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
269.	Have you had a problem with a hiatal hernia?	Never had one / don't know Probably had one/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
270.	Do you have an abdominal hernia?	Don't know I've never had one In the past only, now repaired Minor problem Major problem
271.	Have you been diagnosed with Irritable Bowel Syndrome (IBS)?	No / don't know Mild, in the past, now resolved Serious, in the past, now resolved Current minor problem Current major problem
272.	Do you have Atrophic Gastritis? This a reduction in the number of functioning stomach cells, seen mainly in the elderly.	Don't know No, definitely not Current minor problem Current major problem
273.	Have you had Gastritis?	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
274.	Have you had gastric / stomach / peptic ulcers?	Don't know No, ulcer has been ruled out Past episode now resolved Current minor problem Current major / chronic problem
275.	Have you had any bacterial infections in your stomach or intestines? This would include such things as Helicobacter pylori, Clostridium difficile, etc..	Don't know No Yes    More questions later...
276.	Have you had any physical / inflammatory problems with your large intestine / lower small intestine? This would include inflammatory bowel disease, polyps, diverticulosis, etc..	Don't know No Yes    More questions later...
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