Preliminary questionnaire

1
Name or client number* This field is required.
2
Age
3
Height
4
Weight
5
Waist measurement (at 1 inch above your belly button)
6
Blood pressure (if known)
7
Health concern 1 + medications* This field is required.Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
8
Health concern 2 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
9
Health concern 3 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
10
Health concern 4 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
11
Health concern 5 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
Huge
Large
Normal
Small
Ok
Ok
12
Any other medications or health concerns?
13
Have you recently experienced persistent or regular pain in any of the following?
Head
Temples
Eyes
Abdomen
Chest
On passing urine
14
If you ticked any of the preceding options, please provide more information
Huge
Large
Normal
Small
Ok
Ok
15
Have you recently experienced blood in any of the following?
Sputum
Vomit
Urine
Stools
16
If you ticked any of the preceding options, please provide more information
Huge
Large
Normal
Small
Ok
Ok
17
Have you recently experienced changes in any of the following?
Mood (e.g. negative thoughts)
Thirst
Urination
Bowel habits
Skin/pallor
Vision
Breathing
Weight
Appetite
Body/face shape
Swallowing
Non-menstrual vaginal bleeding
18
If you ticked any of the preceding options, please provide more information
Huge
Large
Normal
Small
Ok
Ok
19
Supplement 1 Please give product name, manufacturer, dose and reason for taking
20
Supplement 2 Please give product name, manufacturer, dose and reason for taking
21
Supplement 3 Please give product name, manufacturer, dose and reason for taking
22
Supplement 4 Please give product name, manufacturer, dose and reason for taking
23
Supplement 5 Please give product name, manufacturer, dose and reason for taking
24
Hospitalisations, accidents and serious or chronic illnessesPlease list all that you can remember with approximate dates
25
Life events such as moving house/country, marriage/separation, bereavements, job changes/lossesPlease list all that you can remember with approximate dates
26
Have you had any recent health tests? Please list any tests together with the results if you have them
Alternatively, email a copy of the results or bring them with you to the consultation
27
How often do you eat each day (meals and snacks)?
28
Where do you eat your meals?Tick all that apply
At a table
In front of the TV
At your desk
Other
29
What time is the first food of your day?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
30
What time do you have the last food of the day?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
31
Who does the cooking in your house?
You
Someone else
Other
32
Who does the food shopping in your house?
You
Someone else
Other
33
Do you have any food allergies or intolerances? (please give details)* This field is required.
34
Do you have any particular dietary requirements? (e.g., you are vegetarian, you hate cauliflower, you avoid pork)
35
Do you smoke or vape?
Yes
No
Ex-smoker/vaper
36
If you currently/used to smoke/vape please specify how many cigarettes/e-cigarretes per day and for how long you have smoked
37
Do you drink alcohol?
Yes
No
38
If you drink alcohol, tell me more about when you drink, what you drink and how much
39
Do you use recreational drugs?
Yes
No
Ex-drug user
Other
40
If you use/have used recreational drugs please specify the drug used
41
Do you currently exercise regularly?* This field is required.
Yes
No
Not regularly, but sometimes
42
What type(s) of exercise do you do?
43
How many times a week?
44
For how long do you exercise each time?
45
What do you do to relax? And how often do you do it?* This field is required.
46
How stressed do you feel?Move the slider to indicate your stress level
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
47
Tell me more about what stresses you
48
How well do you sleep?Move the slider to indicate your sleep quality
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
49
What time do you go to bed?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
50
What time do you wake up?
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
51
How many hours of uninterrupted sleep do you get a night?
52
The next section is for women onlyPlease hit skip to omit this section.
ContinueSkip
53
Are you breastfeeding?
Yes
No
54
Have your periods ever stopped for any reason other than pregnancy?
Yes
No
55
Do you have regular periods?
Yes
No
Post-menopause
56
Do you consider your periods to be heavy?
Yes
No
Previously heavy but not now because of menopause
Previously heavy but not now because taking contraceptive pill
57
Have you ever had any miscarriages?
Yes
No
58
Have you started the menopause?
Yes
No
Not sure
59
If yes, please state when
60
How many children have you given birth to, and what are their ages?
61
Mother
62
Father
63
Maternal Grandmother
64
Maternal Grandfather
65
Paternal Grandmother
66
Paternal Grandfather
67
Sisters/brothers
68
Children
69
Digestion* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Reflux, heartburn, coughing after meals
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Bloating
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Diarrhoea
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Constipation
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Blood in stools
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Fat or undigested food in stools
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Parasites, anal itching
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Piles
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Gallstones
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Nausea/vomiting, feeling of fullness
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Belching, passing gas
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Abdominal cramps
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Food allergies/intolerances
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Reflux, heartburn, coughing after meals
Bloating
Diarrhoea
Constipation
Blood in stools
Fat or undigested food in stools
Parasites, anal itching
Piles
Gallstones
Nausea/vomiting, feeling of fullness
Belching, passing gas
Abdominal cramps
Food allergies/intolerances
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
Never/almost never
Row 7, Column 0
Occasional, not severe
Row 7, Column 1
Occasional, severe
Row 7, Column 2
Frequent, not severe
Row 7, Column 3
Frequent, severe
Row 7, Column 4
Never/almost never
Row 8, Column 0
Occasional, not severe
Row 8, Column 1
Occasional, severe
Row 8, Column 2
Frequent, not severe
Row 8, Column 3
Frequent, severe
Row 8, Column 4
Never/almost never
Row 9, Column 0
Occasional, not severe
Row 9, Column 1
Occasional, severe
Row 9, Column 2
Frequent, not severe
Row 9, Column 3
Frequent, severe
Row 9, Column 4
Never/almost never
Row 10, Column 0
Occasional, not severe
Row 10, Column 1
Occasional, severe
Row 10, Column 2
Frequent, not severe
Row 10, Column 3
Frequent, severe
Row 10, Column 4
Never/almost never
Row 11, Column 0
Occasional, not severe
Row 11, Column 1
Occasional, severe
Row 11, Column 2
Frequent, not severe
Row 11, Column 3
Frequent, severe
Row 11, Column 4
Never/almost never
Row 12, Column 0
Occasional, not severe
Row 12, Column 1
Occasional, severe
Row 12, Column 2
Frequent, not severe
Row 12, Column 3
Frequent, severe
Row 12, Column 4
1 of 13
70
Energy* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent energy dips
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Feel shaky after skipping a meal
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Need to eat to keep up energy
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Poor stamina, constantly tired
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
"Wired" feelings, restlessness
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Feel cold, cold hands and feet
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Frequent energy dips
Feel shaky after skipping a meal
Need to eat to keep up energy
Poor stamina, constantly tired
"Wired" feelings, restlessness
Feel cold, cold hands and feet
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
1 of 6
71
Appetite, weight* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Weight gain/overweight
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Cravings, binge eating
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Frequent dieting
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Weight loss/underweight
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Poor appetite
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Water retention
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Weight gain/overweight
Cravings, binge eating
Frequent dieting
Weight loss/underweight
Poor appetite
Water retention
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
1 of 6
72
Immunity* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent infections
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Swollen glands/tonsilitis
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Allergies (e.g., asthma, eczema, hay fever)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Auto-immune condition
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Frequent infections
Swollen glands/tonsilitis
Allergies (e.g., asthma, eczema, hay fever)
Auto-immune condition
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
1 of 4
73
Head* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Headache, migraine
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Faintness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Dizziness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Headache, migraine
Faintness
Dizziness
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
1 of 3
74
Mind, nervous system* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Poor memory
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Word-finding difficulties
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Difficulty concentrating, brain fog
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Low mood, anxiety, personality changes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Obsessive, compulsive behaviours
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Poor physical coordination, clumsy, tremors, slurred speech
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Poor memory
Word-finding difficulties
Difficulty concentrating, brain fog
Low mood, anxiety, personality changes
Obsessive, compulsive behaviours
Poor physical coordination, clumsy, tremors, slurred speech
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
1 of 6
75
Nose, mouth throat* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Bleeding gums
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Mouth ulcers
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Cold sores
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
White coating on tongue, sore tongue
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Stuffy nose
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Sinus problems
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Excessive mucus formation
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Nose bleeds
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Poor sense of smell
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Sensitivity to smells
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Chronic coughing
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Bleeding gums
Mouth ulcers
Cold sores
White coating on tongue, sore tongue
Stuffy nose
Sinus problems
Excessive mucus formation
Nose bleeds
Poor sense of smell
Sensitivity to smells
Chronic coughing
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
Never/almost never
Row 7, Column 0
Occasional, not severe
Row 7, Column 1
Occasional, severe
Row 7, Column 2
Frequent, not severe
Row 7, Column 3
Frequent, severe
Row 7, Column 4
Never/almost never
Row 8, Column 0
Occasional, not severe
Row 8, Column 1
Occasional, severe
Row 8, Column 2
Frequent, not severe
Row 8, Column 3
Frequent, severe
Row 8, Column 4
Never/almost never
Row 9, Column 0
Occasional, not severe
Row 9, Column 1
Occasional, severe
Row 9, Column 2
Frequent, not severe
Row 9, Column 3
Frequent, severe
Row 9, Column 4
Never/almost never
Row 10, Column 0
Occasional, not severe
Row 10, Column 1
Occasional, severe
Row 10, Column 2
Frequent, not severe
Row 10, Column 3
Frequent, severe
Row 10, Column 4
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Eyes, ears, skin, nails, hair* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Itchy skin, rashes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Easy bruising, slow wound healing
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Brittle nails, white spots, ridges on nails
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Hair loss, dry brittle hair
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Excessive hair growth
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Itchy, red, sore eyes
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Itchy ears, earaches, ear infections
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Ringing in ears
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Hearing loss
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Thinning eyebrows
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Itchy skin, rashes
Easy bruising, slow wound healing
Brittle nails, white spots, ridges on nails
Hair loss, dry brittle hair
Excessive hair growth
Itchy, red, sore eyes
Itchy ears, earaches, ear infections
Ringing in ears
Hearing loss
Thinning eyebrows
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
Never/almost never
Row 7, Column 0
Occasional, not severe
Row 7, Column 1
Occasional, severe
Row 7, Column 2
Frequent, not severe
Row 7, Column 3
Frequent, severe
Row 7, Column 4
Never/almost never
Row 8, Column 0
Occasional, not severe
Row 8, Column 1
Occasional, severe
Row 8, Column 2
Frequent, not severe
Row 8, Column 3
Frequent, severe
Row 8, Column 4
Never/almost never
Row 9, Column 0
Occasional, not severe
Row 9, Column 1
Occasional, severe
Row 9, Column 2
Frequent, not severe
Row 9, Column 3
Frequent, severe
Row 9, Column 4
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77
Joints, bones, muscles* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Joint pain, stiffness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Sore, tender muscles
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Arthritis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Back pain
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Feeling of weakness in muscles
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Loss of muscle mass
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Osteoporosis
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Joint pain, stiffness
Sore, tender muscles
Arthritis
Back pain
Feeling of weakness in muscles
Loss of muscle mass
Osteoporosis
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
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78
Heart and circulation* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
High blood pressure
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Low blood pressure, dizziness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Palpitations
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Chest pain
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Poor circulation
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Pain in calves on walking
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Anaemia
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
High blood pressure
Low blood pressure, dizziness
Palpitations
Chest pain
Poor circulation
Pain in calves on walking
Anaemia
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
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79
Lungs* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Asthma, bronchitis
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Chronic obstructive pulmonary disease
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Shortness of breath, difficulty breathing
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Asthma, bronchitis
Chronic obstructive pulmonary disease
Shortness of breath, difficulty breathing
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
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80
Urinary tract* This field is required.Please rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent urination
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Waking in night to urinate
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Frothy, smelly urine
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Urinary infections (cystitis)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Frequent urination
Waking in night to urinate
Frothy, smelly urine
Urinary infections (cystitis)
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
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81
HormonesPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Low thyroid function
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Overactive thyroid
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Painful or heavy periods
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Menopause symptoms
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Polycystic ovary syndrome
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Infertility
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Loss of libido/erectile dysfunction
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Prostatic enlargement
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Low thyroid function
Overactive thyroid
Painful or heavy periods
Menopause symptoms
Polycystic ovary syndrome
Infertility
Loss of libido/erectile dysfunction
Prostatic enlargement
Never/almost never
Row 0, Column 0
Occasional, not severe
Row 0, Column 1
Occasional, severe
Row 0, Column 2
Frequent, not severe
Row 0, Column 3
Frequent, severe
Row 0, Column 4
Never/almost never
Row 1, Column 0
Occasional, not severe
Row 1, Column 1
Occasional, severe
Row 1, Column 2
Frequent, not severe
Row 1, Column 3
Frequent, severe
Row 1, Column 4
Never/almost never
Row 2, Column 0
Occasional, not severe
Row 2, Column 1
Occasional, severe
Row 2, Column 2
Frequent, not severe
Row 2, Column 3
Frequent, severe
Row 2, Column 4
Never/almost never
Row 3, Column 0
Occasional, not severe
Row 3, Column 1
Occasional, severe
Row 3, Column 2
Frequent, not severe
Row 3, Column 3
Frequent, severe
Row 3, Column 4
Never/almost never
Row 4, Column 0
Occasional, not severe
Row 4, Column 1
Occasional, severe
Row 4, Column 2
Frequent, not severe
Row 4, Column 3
Frequent, severe
Row 4, Column 4
Never/almost never
Row 5, Column 0
Occasional, not severe
Row 5, Column 1
Occasional, severe
Row 5, Column 2
Frequent, not severe
Row 5, Column 3
Frequent, severe
Row 5, Column 4
Never/almost never
Row 6, Column 0
Occasional, not severe
Row 6, Column 1
Occasional, severe
Row 6, Column 2
Frequent, not severe
Row 6, Column 3
Frequent, severe
Row 6, Column 4
Never/almost never
Row 7, Column 0
Occasional, not severe
Row 7, Column 1
Occasional, severe
Row 7, Column 2
Frequent, not severe
Row 7, Column 3
Frequent, severe
Row 7, Column 4
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