Health questionnaire
This questionnaire is strictly confidential.
 * Please fill it out with as much detail as possible.
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1/NAME first name 
2/ age  
Date of the day 
MM
/
DD
/
YYYY
Phone number 
Address ( city / country only needed ) 
Mail address 

Profession and Personal Situation (single/ married/ number of children)
Have you ever had surgery? (Specify the year and reason)


Are you currently on any medication? (Including contraceptive pill, IUD, or implant)

1.Name of the medication
2.For how long
3.Doctor's diagnosis 
Do you have any allergies? Please specify:
1/ the nature 
2/ for how long 
3/ symptoms 
Consumption of the following substances, specifying frequency and quantity:
1. Coffee 
2. Tobacco 
3. Alcohol 
4. Soda, sugary drinks
 5. Sugar (cakes, pastries) 
6. Cannabis 
7. Other drugs

Reason(s) for consultation (list the primary reason first)
1/How long has it been present?
2/Origin of the issue
3/What improves the symptoms?
4/What worsens the symptoms?
5/If there is a medical opinion, what is the diagnosis?

Do you feel abnormally tired?
1/Since when? Add the reason if known.
2/Constant fatigue as soon as you open your eyes?
3/Unexplained fatigue (you eat well, sleep well, and do not engage in intense physical activity during the day)


Do you tend to feel more warm? Or more cold? Or neither warm nor cold?
1/ Do you experience localized sensations of heat? (Example : only in the hand, or in the feet, torso, head, chest, etc. be precise)
2/ have you noticed this sensation happening during the day or evening/night 
1/do you experience localized sensations of cold? (in the hands, or in the feet, torso, head, chest, lower back, etc,be precise.)
2/ have you noticed this sensation happening during the day or evening/night 
If you feel a sensation of cold:
Is it relieved by covering yourself?
Or not relieved by covering yourself?
Do you have fever:
If yes, is there a specific time it tends to appear? (morning, daytime, evening)
Are you sensitive to cold or do you experience chills?
Do you experience a lack of perspiration even during physical effort?
Do you sweat abundantly with the slightest effort?
Is your perspiration strongly odorous or rather without any particular smell?
1/Is your perspiration localized?
(Example: hands / head / feet / chest or other – specify the area)
Do you sweat at night?
Is your perspiration cold or hot?
Or neither?
Do you have an aversion to certain climates?
1. Cold
2. Heat
3. Wind
4. Humidity
5. Dryness
Do you have phlegm in your throat:
a. Specify the color: white, yellow, translucent, other.
b. When you notice : in the morning? all day long
Pain in a part of the body. Please specify:
1/where exactly 
2/ type of pain: 
3/ when does it happen ? 

Do you have any Headaches, if yes please specify:
a. Location: in the forehead, on the sides of the head, at the back, etc.
b. Frequency: how many times per day or per week?
c. When: upon waking, during the day, in the evening, at night.
Do you have acid reflux ? 
1/ when : all the time or during meal or after meal 
2/ since how long ? 
Do you have tinnitus? If yes, since when
Dizziness. If yes:
a. since when
b. vision of small stars or white dots?
Do you have any vision problems?
Tingling or numbness sensations. If yes, specify :
a/ location 
b/ frequency : every day 
C/ when : morning, day, evening , night
Presence of spasms. If yes: 
a/ location 
b/ frequency : every day 
C/ when : morning, day, evening , night

Tremor or nervous tic( example leg )  If yes, specify:
a/ location 
b/ frequency : every day 
C/ when : morning, day, evening , night
Skin itching: if yes : 
 a/ location 
b/ frequency : every day/week 
C/ when : morning, day, evening , night

Skin redness. Specify: 
a/ location 
b/ frequency 
C/ when : morning, day, evening , night
Do you experience dryness in these areas?
How thirsty you are ?
1/Specify the amount of water you drink per day (in glasses or onces) 
2/Do you eat fruit during the day? Specify the amount
How is your urination?
What is the color of your urine?

1. Give the number of the shape of your stools according to the drawing: the last 7 days. It can be different number. 

2. Specify the color: whity brown, brown, dark brown, black.


3. a/ How many times per day do you have a bowel movement?
 b/ How many per week 

Captionless Image
How is your appetite?
Do you have these following symptoms when eating?
Eating habits:
Describe a typical day:
1/ breakfast + drinks  ( number included ) 
2/ lunch + drinks  ( number included ) 
3/ , snacks + drink  ( number included ) 
4/ dinner + drinks ( number included ) 
What is the quality of your sleep?
1. How many hours do you sleep per night on average?

2. If you experience nighttime awakenings:
a. The time, if it's the same 
b. The reason (if there is one: urination, sweating ) 

3/ what time you fall asleep ? 
Emotionally, how are you feeling?
How is your libido?
a. absent without desire to change
b. absent, you'd like it to improve
c. you are satisfied
d. too excessive, you'd like it to be regulated
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