Dr Twyman's Questionnaire
Email address *
First and Last Name *
What is your goal that you would like to achieve by working with Dr Twyman? *
Who referred you to this practice? (If I have seen you previously in the office, then who originally referred you to be seen?) *
Have you experienced any of the following symptoms in the past 48 hours: • fever or chills. • cough. • shortness of breath or difficulty breathing • fatigue • muscle or body aches • headache • new loss of taste or smell • sore throat • congestion or runny nose • nausea or vomiting • diarrhea *
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? *
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *
Are you currently waiting on the results of a COVID-19 test? *
What is your current exercise routine? Do you do any weight lifting/resistance training and if so how much? What type of cardio do you do? *
Do you follow a particular diet or nutrition plan? If so what is it (paleo, keto, low carb, vegan, vegetarian, whole 30, or any named “diet”) *
What time of day do you start eating or drinking anything other than water? *
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What time of the day do you stop eating or drinking anything other than water? *
Time
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What do you normally eat for breakfast? *
How many ounces of protein do you eat at each meal? How many ounces in a day? *
How many times in a normal week do you eat fish or seafood? *
What type of water do you normally drink? (Tap, Spring, Glacial, Reverse Osmosis) *
How many hours of sleep do you normally get? *
What is your normal bedtime? *
Time
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What time do you wake up? *
Time
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Do you have any issues falling asleep or staying asleep? *
Do you take supplements or medications to sleep? *
Do you snore or have you been diagnosed with sleep apnea? *
How much time do you spend in front of technology with screens (TV, Phone, Tablet, or Computer) *
How much time do you spend inside under LED or florescent lighting? *
(iPhone Users Only): What is the daily average “screen time”? Search for “Screen Time” in the “Settings” *
Do you have blue blocking glasses? *
If you have blue blocking glasses, then what brand/type do you use? *
How much time do you wear blue blocking glasses? *
How much time do you spend outside on a normal day *
Do you smoke tobacco? Were you a previous smoker and if so when did you quit? *
If you drink alcohol, how many drinks do you have in a normal week? *
If you drink caffeinated beverages, What do you drink and how many servings in a normal day? *
Did your mother have any heart conditions, cancers, or autoimmune diseases? If yes, then what type *
If you know your mitochondrial maternal haplotype, then what is your haplotype? *
Did your mother’s mother (your maternal grandmother) have any heart conditions, cancers, or autoimmune diseases? If yes, then what type *
Do you take any medications or supplements for cholesterol lowering? If so what are the names and dosages *
If you took any medications or supplements for cholesterol lowering in the past and stopped for any reason, then please list what you tried and any side effects if you had any side effects *
List all prescription medications that you take (Please include dosages) *
List all supplements that you take (Please include dosages) *
What is the name of your medical insurance carrier? (This information is needed to help with ordering labs if you want to ) *
A copy of your responses will be emailed to the address you provided.
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