COMPREHENSIVE WELLNESS QUESTIONNAIRE
functionalnaturopath.com
functionalnaturopath@gmail.com
Thank you for choosing a Functional Naturopathic Approach. Our ability to draw effective
information about your state of health and how to optimize its improvement depends largely on
the accuracy of the information in which you provide, including symptoms that you may
consider minor. Health issues may be influenced by many factors; therefore, it is important that
you carefully consider the questions asked in this form as well as those posed by the Naturopath
during your consultation. This will assist our goal to provide you with an optimal plan of holistic
wellness, to enhance our efficiency, and will provide effective use of your scheduled time. This
questionnaire is not meant to treat or diagnose, dis-ease, but to get a clearer picture of your
overall health history.
Date:
.
First Name:
Middle:
Last:
.
Address ________________________________ City _________________ State _____ Zip
Code
.
Home Phone (____) _____-_______ Work (____) _____-_______ Cell (____) ____-_______
Email _____________________________________
Age _____ Date of Birth ____/____/_____ Place of birth________________ Gender:
Female__Male___
City or town & country, if not US
Referred by:
.
Marital Status:
Single____ Married____ Divorced____ Widowed____ Long Term Partnership____
Emergency Contact: Name:
Phone:
.
Occupation _______________________________________ Hours per week _________ Retired
Height:
Bone Mass:
Weight:
Body Fat%:
(leave blank if you don’t know)
Muscle Mass%:
TBW:
Section I
Part 1: Psycho-Spiritual Survey
Check any that you harbor or are experiencing for yourself or towards others
___Anger___Bitterness___Depression___Fear___Grief___Gossip___Helplessness
___Hoplessness___Loneliness___Guilt___Betrayal___Envy___Jealousy
___Insecurity___Impatient___Arrogance___Pride___Hatred___Rage___Resentment
___Revenge___Shame___Sorrow___Regret___Passivity___Slander___Possessiveness
___Rebellion___Unforgiveness___Gambling___Addictions (Explain)___Other
(Explain)______________________________________________________________________
________________________________________________________________________
Part 2: Air
Check what currently applies to you
___I am always indoors___Do not regularly change home air filter___Home has mold
___Home has an air ionizer___Have plenty of green plants in my living space
___Practice deep breathing exercises regularly, especially outdoors
___I live away from city smog ___Dizziness ___Headaches___Watery eyes
___Sneezing___Cough regularly___Fatigue___Smoke cigarettes regularly
Part 3: Water
Check which currently apply
___Dry mouth, dry eyes, dry nasal membranes
___Dry or leathery skin
___Dry or chapped lips
___Stools hard & Dry
___Low volume of urine, urinate infrequently
___Dark urine (dark yellow or orange)
___Poor skin turgor (loss of elasticity of skin)
___Headaches
___Leg and arm cramps
___Weakness
___Drink less than eight 8 ounces glasses of water daily
Part 4: Light
Check which currently applies
___Depression___Poor bone health___Low vitamin D levels
___Outdoors at least 30 minutes a day
Part 5: EMF
Check what you are presently experiencing
___Headaches___Nausea___Brain fog___Sleep disorders___Loss of memory
___Sensitive skin___Dizziness___Burning sensation___Rash___Vision problems
___Chest pains___Swollen lymph nodes___Live near electrical towers
___Teeth & jaw pain___Constantly having cell phone to the ears
___On computer more than six hours___Aching muscles___Fatigue
___Bouts of unexplained fear or anxiety
___Tingling or prickly sensation across face or other parts of body
___Feeling of impeding influenza but never quite breaks out
Part 6: Exercise
Check which currently applies
___Exercise regularly at least twice a week___Fatigue___Weight gain___Weakness
___Muscle atrophy___Depression___Lack of flexibility and good balance
___Heart problems
Part 7: Fiber
Check which presently applies to you
___Painful or hard bowel movements___Constipated, less than 1 bowel movement a day
___Varicose veins___hemorrhoids or rectal fissures___Use lots of toilet paper to clean yourself
___Stools are pencil size and drop to the bottom of the toilet.
Part 8: Diet
Check what currently applies to you
___Consume six types of vegetables daily
___Eat at least two types of fruit daily
___Consume at least an ounce of raw nuts daily
___50% of my diet is made up of raw foods
___I do not consume dairy, wheat or gluten containing foods
___I consume very little dairy or gluten (2 to 3 meals a week)
___Eat fresh and/or organic foods as much as possible
___Vegetarian___Vegan
___Eat white fish two to three times a week
How often do you consume the following foods?
Answer: daily/weekly/more than once a week
Fried foods__________________________Fatty meats/lunch meats______________________
Soft drinks___________________________Candy or gum_____________________________
Commercial pizza_____________________Pork meat_________________________________
Bottom dwelling fish (shrimp, lobster, clams, etc._____________________________________
Refined white flour products (bread, rice, pasta, etc.)___________________________________
Commercial Cookies/desserts_____________________________________________________
Margarine___________________________
Describe Your Typical Daily Diet: Indicate at What time You Eat
Breakfast
Lunch
Dinner
Snacks
Check which blood type you are:
___A___AB___B___O
Check which body type you are:
___Ectomorph (thin boned, small frame)___Mesomorph (Muscular type, broad shoulders)
___Endomorph (Large bones, round face)
Part 9: Toxic Survey
Check which currently applies
Section A: General toxicity
___Allergies___Chronic Headaches/migraines___Chronic skin problems___Digestive problems
___Diabetes___Auto immune disease___Difficulty sleeping___Depression/poor mood
___Low energy___Liver dysfunction___Overweight___Sore muscles or stiff joints
___Unhealthy cravings___Chemical sensitivities/Environmental illness___Sleepy after meals
___Food allergies/food intolerance
Section B: Heavy Metals
___High blood pressure___Numbness and tingling in extremity
___Twitching of face and other muscles___Tremors or shakes of hands, feet, head, etc.
___Jumpy, jittery, nervous___Unexplained chest pains___heart beat over 100 per minute
___unexplained rashes or skin irritations___Excessive itching
___Bloated feeling most of the time___Frequent or reoccurring heart burn
___Constipated on regular basis___Frequent diarrhea___Depression___Unexplained irritability
___Sudden, unexplained or unsolicited anger___Constant death wish or suicidal intent
___Difficulty in making simple decisions
___Cold hands or feet, even in warm or moderate weather___Out of breath easily
___Headaches after eating___Frequent leg cramps___Frequent metallic taste in mouth
___Burning sensation on the tongue___Constant or frequent ringing of the ears
___Frequent urination during the night___Unexplained chronic fatigue
___Poor or failing memory___Constant or frequent pain in joints___ frequent insomnia
___Unexplained fluid retention
Section 10: Parasite Survey
Check which presently or frequently applies to you
___Gas___Bloating___Abdominal fullness___Nausea___Constipation___Diarrhea
___Abdominal cramps or pain___Fatigue___Hives___Allergies, especially foods
___History of parasitic infections___History of traveler’s diarrhea
___Difficulty overcoming intestinal yeast growth
Part 11: Yeast Survey
Check which presently or frequently applies to you
___Gas___Bloating___Constipation and/or diarrhea___Spastic/irritable colon
___Chrohn’s disease, colitis___Intestinal cramping___Heart burn___Itchy anus
___Continuous sinus problem
___Chronic or reoccurring sore throat, colds, bronchitis, ear infection
___Premenstrual symptoms___Menstrual cramps and problems___fatigue___Depression
___Irritability___Inability to concentrate___Headaches
___Recurrent or chronic vaginal yeast infections___Infertility___Chronic rashes
___Recurrent bladder infections or irritation___Reccurent staph infections
___Itchy ears or ringing in the ears___General itching___Multiple Allergies___Weight problems
___Craving for sweet, alcohol, bread, cheese___Feel drunk without having ingested alcohol
___Chemical and fume intolerance
___Worsening of any of the above symptoms within six to twelve months after a pregnancy
___Multiple pregnancies___Antibiotic use___Birth control pill (oral contraceptives) use
___Cortisone or steroid use___Chemotherapy or radiation
Section II
Part A
Elemental Survey
Circle What You Are Currently Experiencing:
Element
Incidence of Deficiency
Typical Symptoms and Conditions
Biotin
Uncommon
Dermatitis, eye inflammation, hair loss, loss of muscle
control, insomnia, muscle weakness
Calcium
Average diet contains 40 to 50% of
RDA*
Brittle nails, cramps, delusions, depression, insomnia,
irritability, osteoporosis, palpitations, periodontal
disease, rickets, tooth decay
Chromium
90% of diets deficient
Anxiety, fatigue, glucose intolerance, adult-onset
diabetes
Anemia, arterial damage, depression, diarrhea, fatigue,
fragile bones, hair loss, hyperthyroidism, weakness
Copper
Essential fatty
acids
Diarrhea, dry skin and hair, hair loss, immune
impairment, infertility, poor wound healing,
premenstrual syndrome, acne, eczema, gall stones, liver
degeneration, headaches when out in the hot sun,
sunburn easily or suffer sun poisoning
Increased secretion from mouth, nose, eyes. Swelling in
hands and feet, muscle cramps, Menstrual cramps, low
exercise tolerance, cold hands and feet, bleeding gums,
low immunity, fatigue, muscles more flabby than
normal, hair loss, splitting hair and nails, low heart rate,
hypoglycemia.
Protein
Decreased secretions from mouth,nose,eyes Muscle
weakness, inability to concentrate, easily startled,
difficulty swallowing, voice affected by stress
Carbohydrates
Average diet contains 60% of RDA*;
deficient in 100% of elderly in one
study; deficient in 48% of adolescent
girls; requirement doubles in
pregnancy
Anemia, apathy, diarrhea, fatigue, headaches, insomnia,
loss of appetite, neural tube defects in fetus, paranoia,
shortness of breath, weakness
Iodine
Uncommon since the supplementation
of salt with iodine
Cretinism, fatigue, hypothyroidism, weight gain
Iron
Most common mineral deficiency
Anemia, brittle nails, confusion, constipation,
depression, dizziness, fatigue, headaches, inflamed
tongue, mouth lesions
Folic acid
Magnesium
75 to 85% of diets deficient: average
diet contains 50 to 60% of RDA*
Anxiety, confusion, heart attack, hyperactivity,
insomnia, nervousness, muscular irritability,
restlessness, weakness, hypertension
Manganese
Unknown, may be common in women
Atherosclerosis, dizziness, elevated cholesterol, glucose
intolerance, hearing loss, loss of muscle control, ringing
in ears
Niacin
Commonly deficient in elderly
Bad breath, canker sores, confusion, depression,
dermatitis, diarrhea, emotional instability, fatigue,
irritability, loss of appetite, memory impairment,
muscle weakness, nausea, skin eruptions and
inflammation, high cholesterol or triglycerides, poor
circulation.
Pantothenic
acid (B5)
Average elderly diet contains 60% of
RDA*
Abdominal pains, burning feet, depression, eczema,
fatigue, hair loss, immune impairment, insomnia,
irritability, low blood pressure, muscle spasms, nausea,
poor coordination
Potassium
Commonly deficient in elderly
Acne, constipation, depression, edema, excessive water
consumption, fatigue, glucose intolerance, high
cholesterol levels, insomnia, mental impairment, muscle
weakness, nervousness, poor reflexes
Pyridoxine
(B6)
71% of male and 90% of female diets
deficient
Acne, anemia, arthritis, eye inflammation, depression,
dizziness, facial oiliness, fatigue, impaired wound
healing, irritability, loss of appetite, loss of hair, mouth
lesions, nausea
Deficient in 30% of elderly Britons
Blurred vision, cataracts, depression, dermatitis,
dizziness, hair loss, inflamed eyes, mouth lesions,
nervousness, neurological symptoms (numbness, loss of
sensation, "electric shock" sensations), seizures.
sensitivity to light, sleepiness, weakness
Average diet contains 50% of RDA
Growth impairment, high cholesterol levels, increased
incidence of cancer, pancreatic insufficiency (inability
to secrete adequate amounts of digestive enzymes),
immune impairment, liver impairment, male sterility
Thiamin
Commonly deficient in elderly
Confusion, constipation, digestive problems, irritability,
loss of appetite, memory loss, nervousness, numbness
of hands and feet, pain sensitivity, poor coordination,
weakness, slow heart beat or rapid heartbeat, enlarged
heart, heart palpitations.
Vitamin A
20% of diets deficient
Acne, dry hair, fatigue, growth impairment, insomnia,
hyperkeratosis (thickening and roughness of skin),
immune impairment, night blindness, weight loss
Vitamin B-12
Serum levels low in 25% of hospital
patients
Anemia, constipation, depression, dizziness, fatigue,
intestinal disturbances, headaches, irritability, loss of
vibration sensation, low stomach acid, mental
Riboflavin
Selenium
disturbances, moodiness, mouth lesions, numbness,
spinal cord degeneration
Vitamin C
20 to 50% of diets deficient
Bleeding gums, depression, easy bruising, impaired
wound healing, irritability, joint pains, loose teeth,
malaise, and tiredness.
Vitamin D
62% of elderly women's diets
deficient. It is said that 80% of USA
population is deficient.
Burning sensation in mouth, diarrhea, insomnia,
myopia, nervousness, osteomalacia, osteoporosis,
rickets, scalp sweating, poor immunity.
Vitamin E
23% of male and 15% of female diets
deficient
Gait disturbances, poor reflexes, loss of position sense,
loss of vibration sense, shortened red blood cell life
Vitamin K
Deficiency in pregnant women and
newborns common
Bleeding disorders, arteriolosclerosis, spurs, calcium
deposits.
68% of diets deficient
Acne, amnesia, apathy, brittle nails, delayed sexual
maturity, depression, diarrhea, eczema, fatigue, growth
impairment, hair loss, high cholesterol levels, immune
impairment, impotence, irritability, lethargy, loss of
appetite, loss of sense of taste, low stomach acid, male
infertility, memory impairment, night blindness,
paranoia, white spots on nails, wound healing
impairment, low testosterone.
Zinc
Part B: Body Systems Survey
I. Upper GI
Check which you are frequently or presently experiencing
___Belching or gas within one hour after eating___Heartburn or acid reflux___Bad breath
___Bloated within one hour after eating___Loss of taste for meat___Sweat has strong odor
___Stomach upset by taking vitamins___Feel like skipping breakfast___Sleepy after meals
___Feel better if you do not eat___Fingernails chip, peel or break easily
___Anemia unresponsive to iron___Stomach pains or cramps___Chronic Diarrhea
___Diarrhea shortly after meals___Black or tarry colored stools___Undigested food in stool
II. Liver/Gallbladder
Check which presently or frequently applies
___Pain between shoulder blades___Stomach upset by greasy foods___Greasy or shinny stools
___Nausea___Sea, car, airplane or motion sickness___History of morning sickness
___Light or clay colored stools___Dry skin, itchy feet or skin peels on feet
___Headache over eyes___Gallbladder attack or removed
___Bitter taste in mouth, especially after meals___Become sick if you drink wine
___Easily intoxicated if you drink wine
___Easily hung over if you drink wine
How much alcohol do you drink per week?
___I am a recovering alcoholic___History of drug or alcohol abuse___History of Hepatitis
___Long term use of prescription or recreational drugs___Sensitive to chemicals
___Sensitive to tobacco smoke___Pain under right side of rib cage
___Hemorrhoids or varicose veins___Chronic fatigue or fibromyalgia
___Nutrasweet consumption___Sensitive to Nutrasweet (aspartame)
III. Small Intestine
Check which currently or frequently applies
___Food Allergies___Abdominal bloating 1 to 2 hours after eating___Pulse speeds after eating
___Specific foods make you tired or burdened___Airborne allergies___Experience hives
___Sinus congestion___Crave bread or noodles___Alternating constipation and diarrhea
___Crohn’s disease___Wheat or grain sensivitity___Asthma, sinus infections, stuffy nose
___Dairy sensitivity___Bizarre, vivid dreams, nightmares___Feel spacy or unreal
___Use over the counter pain medications
IV. Large Intestine
Check which presently or frequently applies
___Anus itches___Coated tongue___Feel worse in moldy or dusty places
___Have taken antibiotics for long periods (2 to 3 months or more)
___Fungus or yeast infection___Ring worm / nail fungus___Blood in stool___Mucous in stool
___Painful to press on outer side of thighs___Cramping in lower abdominal region
___Dark circles under eyes___Excessive foul smelling lower bowel gas
___Irritable bowel or mucous colitis___Strong body odors___Less than 1 bowel movement daily
V. Sugar Handling
Check which presently or frequently applies
___Awaken a few hours after falling asleep, hard to get back to sleep___Crave sweets
___Bing or uncontrolled eating___Excessive appetite
___Crave coffee or sugar in afternoon___Sleepy in the afternoon
___Fatigue that is relieved be eating___Headaches if meals are skipped
___Irritable before meals___Shaky if meals are delayed
___Family members with diabetes___Frequent thirst___Frequent Urination
VI. Adrenal
Check which presently or frequently occurs
___Tend to be a night person___Difficulty falling asleep___Slow starter in the morning
___Keyed up, trouble calming down___Blood pressure above 120/80
___Headache after exercising___Feeling wired or jittery after drinking coffee
___Clench or grind teeth___Calm on the outside, trouble on the inside
___Chronic low back pain, worse with fatigue
___Become dizzy when standing up suddenly
___Difficulty maintaining manipulative correction
___Pain after manipulative correction___Arthritic tendencies___Crave salty foods
___Salt foods before tasting___Perspire easily___Chronic fatigue or get drowsy often
___Afternoon yawning___After headaches___Asthma, wheezing or difficulty breathing
___Pain on the medial or inner side of the knee
___Tendency to sprain ankles or shin splints
___Tendency to need sunglasses___Allergies and/or hives___Weakness, dizziness
VII. Thyroid
Check which presently or frequently you experience
___Sensitive/allergic to iodine___Difficulty gaining weight, even with large appetite
___Nervous, emotional, can’t work under pressure___Inward trembling___Flush easily
___Fast pulse at rest___Intolerant to high temperatures___Difficulty losing weight
___Mentally sluggish, reduced initiative___Easily fatigued, sleepy during the day
___Sensitive to cold, poor circulation (cold hands and feet)
___Chronic constipation___Excessive hair loss and/or coarse hair
___Morning headaches, wear off during the day___Seasonal sadness
___Loss of lateral 1/3 of eyebrow
VIII. Men Only
Check which presently or frequently applies
___Prostate problems___Difficulty with urination or dribbling
___Difficult to start or stop urine stream___Pain or burning with urination
___Waking to urinate at night___Interruption of stream during urination
___Pain on inside of legs or heels___Feeling of incomplete bowel evacuation
___Decreased sexual function
IX. Women Only
Check which presently or frequently applies
___Depression during periods___Mood swings associated with periods (PMS)
___Crave chocolate around period___Breast tenderness associated with cycle
___Excessive menstrual flow___Scanty blood flow during periods
___Occasional skipped periods___Variations in menstrual cycle___Endometriosis
___Uterine fibroids___Breast fibroids, benign masses___Painful intercourse
___Vaginal discharge___Vaginal itchiness___Vaginal dryness
___Weight gain around hips, thighs and buttocks___Excessive facial or body hair
___Thinning skin___Hotflashes___Night sweats (in menopausal women)
X. Cardiovascular
Check which presently or frequently occurs
___Aware of heavily or irregular breathing___Discomfort at high altitudes
___Air hunger or sigh frequently___Compelled to open windows in a closed room
___Shortness of breath with moderate exertion___Ankles swell, especially at end of day
___Cough at night___Blush or face turns red for no reason
___Muscle cramps with exertion
___Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
XI. Kidney and Bladder
Check which presently or frequently occurs
___Pain in mid-back region___Puffy around the eyes, dark circles under eyes
___History of kidney stones___Cloudy, bloody or darkened urine
___Urine has a strong odor
XII. Immune System
Check which presently or frequently occurs
___Runny or drippy nose___Catch colds at the beginning of winter___Adult acne
___Itchy skin___Cysts, boils, rashes___History of Epstein Bar___Frequent colds or flu
___Frequent infections___Mucous producing cough___History of Mono, Herpes
___History of Shingles, Chronic fatigue, Hepatitis or other chronic viral condition
List the Medications you presently take: Prescription and over the counter
_____________________________________________________________
________________________________________________________________________
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List the Vitamin Supplements You Presently Take:
______________________________________________________
________________________________________________________________
________________________________________________________________
List the Medical Conditions You Have Been Diagnosed as Having:
_____________________________________________________
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List Any Operations You Have Had:
_____________________________________________________
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List the Medical Conditions that Run in Your Family
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What Have You Come Here
For?_____________________________________________________