Initial Health Questionnaire Please fill in our initial health questionnaire below. Step 1 of 5 20% Name* First Last Email* Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Mainly for phone/Skype clients if I need to post referrals or supplementsDate of Birth* Age*Male/Female*MaleFemaleHeight in cmNeeded for face to face clients to program the scales.If under 18, what's your guardian's name? How many times a week do you eat fish?*Do you smoke?*YesNoHow many a day?How many alcoholic beverages do you consume in a week?*Do you exercise regularly?*YesNoOn average, how many hours a week?*Do you regularly engage in any of the following exercises?* Walking Running Swimming Biking Yoga/Pilates Gym Other I don't exercise Please list your main health concerns in order of decreasing severity (starting with the worst one)*On a scale of 1 to 10 (10 being the most important), how important is it to you to resolve these issues in the next 3 to 6 months?Who or what do you think is your biggest obstacle to achieving your health goals?What other methods, diets etc have you tried? What didn't work for you and why?Do you have any other commitments that would keep you from being 100% successful in accomplishing your goals? What major illnesses or health complaints have you suffered in the past?What surgery, if any, have you had in the past?Do you have a family history (parents, grandparents or siblings) of any of the following conditions? Diabetes High Cholesterol Heart Disease High Blood Pressure Cancer Arthritis Alzheimer's Osteoporosis Other None Other - please specifyDo you often take antibiotics? When was the last time?Please list any prescriptions or over the counter medications you are currently taking and what you are taking them for?Please list any supplements you are currently taking and what you are taking them for?Do you have any allergies or reactions to chemicals, foods, the environment (pollen, dust etc), medications or supplements? How severe?On a scale of 1-10 (with 10 being extreme), how would you rate your level of stress?On a scale of 1-10 (with 10 being outstanding), how good do you feel your diet is?List the 3 worst foods you eat during an average week.List the 3 healthiest foods you eat during an average week.On a scale of 1-10 (with 10 being outstanding), how do you rate your health and fitness?What is your current weight?What is your ideal weight? HeadingPlease take 5 minutes to complete this section. Tick any items that you are currently or regularly suffer from.Digestion Excessive burping/belching Constipation Alternating constipation/diarrhoea Bad breath Flatulence (gas) GERD (reflux) Bloating (distended abdomen) Cramping/pain Haemorrhoids Frequent use of antacids Coating on tongue Foul smelling stools or gas Nausea Vomiting Regular use of laxatives Gallbladder removed Female Hormones PMS Dysmenorrhoea (painful periods) Hot flushes Infertility Urinary incontinence Low sex drive Cramping/pain Amenorrhoea (no periods) Pregnant Breast feeding Peri-menopause Going through Menopause Post menopause Taking the pill Other hormone therapy PCOS Endometriosis Vaginal yeast infections Male Hormones Impotence / erectile dysfunction Low sex drive Difficulty urinating Pain / burning during urination Dripping after urination Mood / Sleep Anxiety Depression Headaches Migraines Insomnia Difficulty going to sleep Difficulty staying asleep Early waking Irritability Nervousness Mood swings Cardiovascular Raised blood pressure High cholesterol Irregular heart beat Dizziness when standing Heart/chest pain Palpitations/racing heart Varicose veins Poor circulation (cold hands and feet) Skin Psoriasis Eczema Hives Acne Dry skin Dandruff Athletes foot Rosacea Warts/verucas Respiratory Hayfever Allergies Post nasal drip Asthma Difficulty breathing Regular colds/flu Sinusitis Nose bleeds Sore throat Bronchitis Metabolic Fluid retention Frequent urination Excessive thirst Cravings for sweets Tired if you miss a meal Tired after eating Chronic fatigue Need coffee to get started Poor concentration Gain weight easily Other Urinary tract infections Ear infections Sinus infections Viral issues Yeast / Fungal issues Parasites Bacterial infections Joint pain Muscle pain Dizziness/vertigo Back pain This iframe contains the logic required to handle Ajax powered Gravity Forms.
