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Health Questionnaire

Please fill out the below questionnaire before your visit.

How did you hear about us?

Have you had any medical exam test or x-rays in the last 5 years?

Have you ever had any surgical operations?

Are you currently undergoing medical treatment?

Have you every had Radiation or Chemotherapy?

Are you allergic to any foods or environmental substances?

Are you currently taking any prescribed medication?

Are you currently taking any natural supplements?

Do you, or have you ever used recreational drugs?

Have you ever been vaccinated?

Do you have regular flu shots?

Have you experienced any adverse reactions to vaccines?

Do you, or have you ever smoked cigarettes/cigars?

Do you, or have you ever drunk alcohol?

Have you ever worked with chemicals including garden sprays?

Do you have any of the following?

Is there a family history of any conditions?

Have you ever had dental or oral health issues?

Do you grind/clench your teeth?

FEMALE ONLY: Are you currently pregnant?

FEMALE ONLY: Have you been pregnant before?

FEMALE ONLY: Have you had abnormal periods?

FEMALE ONLY: Have you had a miscarriage/abortion in the past?

FEMALE ONLY: Have you experienced any menstrual problems during puberty?

FEMALE ONLY: Are you currently on contraceptives?

FEMALE ONLY: Have you ever been on contraceptives?

FEMALE ONLY: Have you ever been on Hormone Replacement Therapy (HRT)?

FEMALE ONLY: Have you ever had symptoms from contraceptives or HRT?

MALE ONLY: Have you ever had a vasectomy?

MALE ONLY: Have you ever had any prostate issues?

MALE ONLY: Have you ever experienced erectile dysfunction?

Do you have diarrhoea often?

Do you have, or have you had, piles or haemorrhoids?

Do certain foods affect your bowel motions?

Do you get anal itch?

Do you get rectal bleeding?

Have you had recent unexplained weight change?

What colour is your stool normally?

Do you experience difficulty urinating?

Do you experience problems with frequency/urgency of urinating?

What colour is your urine normally?

Do you have any problems maintaining your ideal weight?

Do you feel cold unduly?

Do you drink tea/coffee/fruit juices etc...?

Do you drink tap water?