Significant Healing Well Care Practice
859-282-0022
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Free Health Questionnaire
Please complete all sections below. Results will be emailed to Victoria and she will reply to you . Please allow about 15 minutes to compete.
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Name
*
First
Last
Phone Number
*
Please provide a phone number if you would like our office to follow up with you.
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Do you currently have an appointment with Victoria?
*
Yes
No
Please chose the most accurate answer below.
Once you answer this extensive questionnaire, Victoria will review
your response personally and reply via email.
Eyes
Watery, Itchy Eyes
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Never or almost never.
Occasionally, NOT severe.
Occasionally, severe.
Frequently, not severe.
Frequently, severe.
Dark Circles Under Eyes
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1. No.
2. Lightly.
3. Dark circles.
Swollen, Reddened or Sticky Eyelids
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Never.
Occassionally.
Every morning only.
Blurred Tunnel Vision
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1. Never.
2. Sometimes.
3. Always.
4. Without glasses.
Ears
Itchy Ears
*
Inside ears itch always.
Inside ears itch occassionally.
Not at all.
Drainage from Ears
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Yes.
Sometimes.
Never.
Hearing Loss
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Yes, one ear.
Both ears.
No.
Ear Aches, Ear Infections
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Frequent earache / infection.
Once or twice yearly.
Never or almost never.
Stuffy Nose
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Seasonal allergies cause.
Occasionally.
Year round.
Never.
Nose
Stuffy Nose
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Yes, always.
Yes, sometimes.
No.
Hay Fever
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Severe.
Mild.
Never.
Excessive Mucous
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Severe.
Mild.
Never.
Sinus Problems
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Seasonally, severe.
Seasonally, mild.
Year round, severe.
Year round, mild.
Never.
Sneezing Attack
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Daily.
Once or twice a week.
Two or more times weekly.
Never.
Mouth/Throat
Chronic Coughing
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Severe.
Mild.
Never.
Soar Throat/Hoarseness
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Always.
Frequently.
Occassionally.
Never.
Canker Sores
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Frequently.
Occasionally.
Never.
Gagging, Frequent Need to Clear Throat
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Frequently.
Occasionally.
Never.
Swollen or Discolored Tongue, Gums, or Lips
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Always.
Occasionally.
Never.
Amaglam Dental Fillings
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Yes.
No.
All have been removed.
Head
Dizziness
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Frequently.
Occasionally.
Never.
Migraines
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Frequently.
Occasionally.
Never.
Faintness
*
Frequently.
Occasionally.
Never.
Insomnia
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Frequently.
Occasionally.
Never.
Headaches
*
Daily.
More than once weekly.
More than once monthly.
Never or almost never.
Heart
Skipped Heartbeats
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Yes.
No.
Chest Pain
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Frequently.
Occasionally.
Never.
Rapid Heartbeats
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Yes.
No.
Tightness in Chest
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Frequently.
Occasionally.
Never.
Lungs
Chest Congestion
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Frequently.
Occasionally.
Never.
Shortness of Breath
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Frequently.
Occassionally.
Never.
Asthma; Bronchitis
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Frequently.
Occasionally.
Never.
Difficulty Breathing
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Frequently.
Occasionally.
Never.
Joints/Muscles
Pain or Aches in Joints
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Frequently, severe.
Frequently, mild.
Occasionally.
Never.
Stiffness/Limited Movements
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Especially in morning.
All day long.
Occasionally.
Never.
Weakness or Tiredness
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Weak muscles.
Tired feeling muscles.
Strong.
Arthritis
*
Osteo Arthritis.
Rheumatoid arthritis.
No.
Pain; Aches in Muscles
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Yes always.
Sometimes.
Never.
Emotions
Mood Swings
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Frequently.
Occasionally.
Never.
Anger, Irritability
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Frequently.
Occasionally.
Never.
Anxiety, Fear, Nervousness
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Frequently severe.
Frequently mild.
Occasionally severe.
Occasionally mild.
Never.
Depression
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Frequently severe.
Frequently mild.
Occasionally severe.
Occasionally mild.
Never.
Mind
Poor Memory
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Frequently.
Occasionally.
Never.
Poor Concentration
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Frequently.
Occasionally.
Never.
Difficulty Making Decisions
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Yes.
No.
Slurred Speech
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Frequently.
Occasionally.
Never.
Learning Disabilities
*
ADD.
ADHD
Dyslexia.
Other.
No.
Palsy/Shaking/Neurological Disturbances
*
Yes, severe.
Yes, mild.
No.
Confusion
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Frequently.
Occasionally.
Never.
Poor Coordination
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Frequently.
Occasionally.
Never.
Stuttering/Stammering
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Yes.
No.
Seizures/Blackouts
*
Yes.
No.
Takes medication to prevent.
Brain Fog/Foggy Feeling
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Yes, severe.
Yes, mild.
No.
Energy/Activity
Fatigue/Sluggishness
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Always tired.
Tired in afternoons.
Always sluggish.
Occasionally tired or sluggish.
No.
Hyperactivity
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Yes.
No.
Apathy/Lethargy
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Yes.
No.
Restlessness
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Yes.
No.
Skin
Acne
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Yes, severe.
Yes, mild.
No.
Flushing or Hot Flashes
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Yes, severe.
Yes, mild.
No.
Eczema/Psoriasis
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Yes, severe.
Yes, mild.
No.
Tattoos
*
No tattoos.
1 or 2 tattoos.
3 or more tattoos.
Hives/Rashes/Dry Skin
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Yes, severe.
Yes, mild.
No.
Hair Loss
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Hair shedding.
Dry hair.
No hair problems.
Excessive Sweating
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Yes.
No.
Skin Fungus/Athletes Foot
*
Nail fungus.
Athletes foot.
Nail fungus and Athletes foot.
Neither.
Digestive System
Nausea/Vomiting
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Frequently.
Occasionally.
Never or almost never.
Constipation
*
At least one BM daily.
One to three BM's weekly.
One or less BM's weekly.
Bloated Feeling
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Frequently severe.
Frequently mild.
Occasionally severe.
Occasionally mild.
Never or almost never.
Parasites
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Yes.
Maybe.
No.
Unsure.
Diarrhea
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Frequently.
Occassionally.
Never or almost never.
Belching/Passing Gas
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Frequently.
Occasionally.
Only normal amounts.
Digestive Burn
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Frequently severe.
Frequently mild.
Occasionally severe.
Occasionally mild.
Never or almost never.
Yeast Infection
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Frequently.
1x year or less.
Never.
Weight
Binge Eating/Drinking
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Yes, occasionally.
Yes, frequently.
No.
Excessive Weight
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Not Overweight.
Less than 10 lbs overweight.
10-30 lbs overweight.
30-60 lbs overweight.
more than 60 lbs overweight.
Water Retention
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Frequently severe.
Frequently mild.
Occasionally severe.
Occasionally mild.
No.
Craving Certain Foods
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Sweets.
Salty.
Protein.
Breads.
Vegetables.
Compulsive Eating
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Yes.
No.
Underweight
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Yes.
No.
Other
Frequent Illness
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Yes.
No.
Genital Itch/Discharge
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Yes.
No.
Daily Consumption of Packaged (Boxed/Bagged) Food
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Yes.
No, only occassionally.
Never.
Frequent or Urgent Need to Urinate
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Yes.
No.
Daily Consumption of Sugar
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One serving daily.
Two ore more servings daily.
Sugar once a week or less.
Never.
Takes Prescription Medication
*
One RX.
Two to three RX.
Four or more RX.
No RX.
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