Life Style Analysis Questionnaire

Your Personal Health Evaluation

[FrontPage Save Results Component]
 

Name: _______________________________________________

 Birth Date:_____________________________
 

Address: _____________________________________________

 Home Phone:___________________________
 

City, State, Zip: ________________________________________

 Alternate Phone:_________________________
 

E-mail Address: __________________________________________

Please read every item carefully and put a check mark in the box next to each item that applies to you. If you do not understand the question, put a question mark (?) in the box. Attach a separate sheet to indicate your main health complaints.  

Please fax completed form to (817) 292-3335.  If you need any help, please call (817) 469-8823.

 1 I am pregnant
 2 I am chemically sensitive      environmentally sensitive
 3 I have cancer or Hepatitis B,C,D... Indicate ___________________
 4 Most of my physical problems disturb me  during the day        during the night
 5 Sensitive to cold such as cold weather, ice water and cold food
 6 Sensitive to heat such as hot weather and rooms without air conditioner
 7 Sweat profusely after doing light physical work such as vacuuming or mopping
 8 Sweat profusely during the night
 9 I have, or had shingles (herpes zoster)
10 Dizziness
11 Pain in the body.  Indicate region of pain _____________ How long? __________
12 Constipation
13 Diarrhea
14 Kidney failure.  I am receiving kidney dialysis. How many times per week? _________
15 Sexual potency problems or lack of sexual desire
16 Heavy alcohol consumption
17 Addictions to:   nicotine    caffeine   cocaine     social drugs.  How long? ____________
18 Frequent use of antibiotics
19 HIV positive
20 Dry skin   itching     skin peeling    acne     age spots
21 Breast implants  Date: ___________    Chemo/radiation therapy      Date:____________
22 Skin disease, skin burn or cut.  Name of skin disease ____________
23 Ear ringing        hearing loss
24 Poor sleep or I wake up at least two times during the night
25 Snore while sleeping
26 Irregular menstrual flow   excessive menstrual flow      early menopause       cramps before menstrual flow
27 Vulva / vaginal itching
28 Amalgam (silver or mercury) fillings in my mouth.    Which tooth __________
29 Root canals.      Which tooth  __________
30 Metal crowns.   Which tooth  __________
31 Toothache.        Which tooth  __________
32 Periodontal or gum disease
33 Hemorrhoids
34 Overweight
35 Thirsty

SECTION L
 1 Ring finger feels weak, sensitive, sore or painful
 2 I sometimes feel hot     I sometimes feel cold       I feel hot and cold in rotation
 3 Skin is discolored
 4 Pain all over my joints
 5 Migraine headaches ( in temple region)
 6 Headaches on top of head
 7 Pain on right side beneath rib
 8 Pain in abdominal / groin area
 9 Pain in outside (lateral side) of  feet
10 Pain or itching in genital region
11 Pain in back of head
12 Neck and shoulders are tight and sore
13 Irritable, impatient or indecisive
14 Depression        stressful lifestyle
15 Had stroke or brain damage
16 Get excited and lose self-control easily
17 Numbness in fingers
18 Difficult to fall asleep   wake up during the night 
19 Irregular bowel movements such as diarrhea and constipation in rotation
20 Mouth odor       armpit odor
21 Bleeding: hemorrhoid      nasal      gum bleeding     other_____________
22 Frequently nauseated     bloated     gassy    experience reflux, belch or burp
23 Abdominal cramps before monthly menstrual cycle
24 Clumsy in physical motor functions
25 Take synthetic medications; have taken for_______years
26 High cholesterol      high triglyceride
27 Vision gradually degraded in recent months
28 Sneeze all year round or catch cold easily
29 Prostate problems; difficult urination or incontinence
30 Hernia in groin area
31 Dizziness
SECTION H
 1 Pain in both shoulders.  Left shoulder pain is more severe than the right
 2 Chest pain
 3 Pain in upper back region or around scapula
 4 Pain in armpit
 5 Palms sweat profusely; pain in palm of hands
 6 Sweat easily and profusely from armpit
 7 3rd and 5th fingers feel weak
 8 Heart palpitations
 9 Mind racing      mental confusion       forgetfulness
10 Heart failure
11 Low or no energy; tire easily
12 Ulcers on tongue and other oral areas
13 Feel thirsty but don't want to drink

SECTION S
 1 Big toe or second toe feel weak
 2 Middle finger feels weak
 3 Knee pain        knee swelling
 4 Pain in left side beneath ribs
 5 Heartburn (pain under sternum)
 6 Symptoms of TMJ joint in jaw
 7 Snore while sleeping
   8 Sclera (white part of eye) or palm is yellowish
 9 Poor appetite
10 Bloated stomach     gassy after eating
11 Stomach ulcer         ulcer in month
12 Retain water and fluids in stomach
13 Dry lips; thirsty all the time
14 Sweet taste in mouth
15 Get hungry easily
16 Can not move tongue easily    pain in tongue
17 Mind is always racing
18 Difficulty falling asleep
19 Wake up frequently
20 Gum disease, especially in lower jaw
21 Periodontal disease
22 Had parasitic/fungal infection 
SECTION P
 1 Thumb and index finger are weak and/or painful
 2 Gum disease, especially in upper jaw
 3 Toothaches in upper teeth
 4 Pain in elbow
 5 Asthma 
 6 Chronic cough
 7 Pain in right shoulder
 8 Emphysema       Other lung disease________________
 9 Constipated 
10 Clumsy or awkward when using tools
11 Short of breath
12 Excessive sputum or phlegm

SECTION K
 1 Hungry, but don't have desire to eat
 2 Sleepy all the time
 3 Sclera (white of eye) is yellowish
 4 Vision is vague
 5 Feel frightened for no reason
 6 Dark facial and/or ear color
 7 Cramping in tendons
 8 Pain in lower back and sacrum area
 9 Knee pain
10 Pain in back of head
11 Abdominal pain
12 Pain and/or heat on bottom of feet
13 Dry skin, hair, eyes
14 Lack of sexual potency or desire
15 Infertile
16 Seminal discharge occurs during sleep
17 Prostate trouble; problem with urination
18 Problem with erection
19 Early ejaculation during intercourse
20 Vaginal dryness, especially during intercourse
21 Vulva / vaginal itching
22 Wake up frequently during the night to go to the bathroom
23 Urinary accidents during sleep
24 Excessive white discharge from vaginal region
25 Hair loss
26 Yawn frequently
27 Periodontal disease
28 Brain disease
29 Bone and/or joint disease such as osteoporosis or arthritis
30 Water retention in ankles
31 Pain in Achilles tendon
32 Take diuretics
33 Hysterectomy        replacement hormone therapy
34 Excessive white clotted discharge
35 I am athletic      I exercise regularly

For over 4,000 years, the Chinese have traditionally used herbal formulas to aid in recovery from various diseases and to promote abundant health.  These suggestions are for your education only.  Any suggestions we may make to assist your recovery are based on the information you provided.  They are not intended to diagnose, treat, cure or prevent any disease.  The decision to take any Chinese herbal formulas is up to you.  The Federal Drug Administration has not evaluated these formulas.  Please provide feedback two weeks after taking the formulas.

Please sign below to indicate your request for review of your medical information.

       Signature: _____________________________________________        Date: ___________________________________

       Print your name ________________________________________

                        May you be blessed with abundant health

 

Alternative Medicine Inc.
Copyright © 1999 [Alternative Medicine Inc.]. All rights reserved.
Revised: December 14, 2004