Health Questionnaire
Integrated Health Solutions Health Questionnaire.

If you are logged into your google account your questions will be saved to your google account, this is optional, if you log out this won't occur. 
Sign in to Google to save your progress. Learn more
Name *
Age
Email *
Mobile Number or Landline with area code *
Diagnosed Medical Conditions (if applicable)  
Do you currently take medication for any diagnosed medical conditions?  
What is your first concern when it comes to your health?   *
Gut Health
Do you experience flatulence more than once daily?
Do you get tired after eating?
Do you have pain after eating?
Do you experience bloating more than once daily?
Do you go two days or more without a motion?
Do you experience loose bowel motions once a week or less?
Do you experience reflux or heartburn once daily?
Do you take Panadol or ibuprofen more than once a month?
Do you react to certain foods?
Does Irritable Bowel Syndrome affect your day to day life?
Do you ever have a sour taste in your mouth?
Do you feel that food "sits" in your stomach?
Microbiome
Have you had antibiotics in the last 5 years?
Do you eat less than 3 cups of vegetables per day?
Do you experience high stress?
Have you tested positive to any other parasites or bacteria?
Do you eat processed foods?
Do you have less than one bowel motion daily?
Have you had an infection or illness where you've never felt quite right again?
Liver
 Are you easily angered or irritable?
 Do you eat a high carbohydrate diet?
 Do your stools float?
 Do you feel tired upon waking?
 Do you eat processed foods?
 Do you prefer not to eat breakfast?
 Do you have tenderness or pain around the bottom of your right rib cage?
Do you smoke?
 Do you take medication regularly?
Do you suffer from Headache?
Do you drink Alcohol?
Immunity
 Do you smoke?
 Do you react to certain foods?
 Do you react to any other environmental factors (eg rain, grass, fibres)?
 Do you experience fatigue or poor energy?
 Do you experience muscle aches and pains?
Do you have white spots on your nails?
Do you have a coated tongue?
Do you use recreational drugs?
Do you drink alcohol?
Adrenals
 Do you have white spots on your nails?
Do you experience high stress in your job?
Do  you experience high stress in your personal life?
Do you feel dizzy when you get up quickly?
Do you sometimes feel like your body is tired but your mind is wired?
Do you experience energy fluctuations throughout the day?
Do you need to eat between 2-4 pm?
Do you consider yourself to have a busy life?
Do you crave salt or sugar?
If you wake during the night can you settle in 30 minutes?
Do you experience your mind racing all the time?
Do you feel like you have not time for yourself?
Do you use an electronic device before bed?
Do you feel tired after exercise?
Does it taken more than 30mins on waking before  you are read to start you day?
Do you experience difficulty concentrating?
Do you have trouble remembering and focusing on things?
Stress
Would you say you experience a busy mind?
Do you get a racing heart or palpitations?
Would you describe yourself as nervous?
Would you feel unmotivated?
Would you feel lethargic?
Do you experience high stress in your life?
Have you had high stress, both emotional and physical in the las few years?
Do you experience shortness of breath?
Would you say that you worry a lot?
Would you say that you are an over thinker?
Do you Catastrophize?
Do you suffer from Anxiety?
Do you have panic attacks?
Do you worry about your health?
Do you care for others before yourself?
Do you care what others think of you?
Toxic Load
Do you use chemical cleaning products at home?
Do you have tattoos?
Do you use plastic containers?
Do you eat vegetables that are not organic?
Do you eat vegetables that are not spray-free?
Do you eat meat that is not organic?
Do you live within 3km of a petrol station?
Do you live within 1km of a petrol station?
Do you see mould growing on items inside your home?
Do you take medication regularly?
Do you have less than one bowel motion daily?
Hormones
Are you using any form of contraceptive device or medication?
Do you have a menstrual cycle lasting less that 25 days
Do you get breakthrough bleeding in between periods?
Do you have painful periods that mean you miss work/life activities?
Do you experience loose bowel motions during, before or after your periods?
Do you experience mid cycle pain?
Do you have heavy periods?
Do you experience acne before your period?
Do you experience acne during your period?
Do you have additional hair on your face or body?
Do you suffer moodiness before your period?
Do you have a low Libido?
Are you fatigued or lethargic before your period?
General
Have you had Covid?
Have you had the Covid Vaccine?
Do you have teeth pain?
Do you have gingivitis?
Do you use recreational drugs?
Do you take iced coffee/iced chocolate drinks?
Do you take energy drinks?
Do you take sports drinks?
By submitting your information, you consent to the way your information is used, as set out here, and in the Terms and Conditions & Privacy Policy on the clinic’s website.


Your Health Report is for educational purposes only.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Integrated Health Solutions.

Does this form look suspicious? Report

Google Forms