Questionnaire

Please put in your client identification number*
Please call Ballina Health Centre if you have not been given your client identification number.
Sex*
- Male
- Female
Date of Birth*

Please enter your date of birth in the format DD/MM/YYYY
Age in years*
Please enter a number from 0 to 100.
Please list your main complaints for which you require treatment:
Please list other associated symptoms or problems:
Section Break
Family History, has your mother ever suffered with any of the following diseases? (Please select applicable conditions)
Family History, has your father ever suffered with any of the following diseases? (Please select applicable conditions)
Family history, have your siblings ever suffered with any of the following diseases? (Please select applicable conditions)
Family history, have other relatives ever suffered with any of the following diseases? (Please select applicable conditions)
Please add any further information about inherited conditions:

Are you allergic to any medications?
- Yes
- No
Please list the medications
Are you allergic or reactive to any chemicals or foods?
- Yes
- No
Please list the chemicals or foods
Are you aware of any digestive, abdominal or bowel symptoms?
- Yes
- No
- Unsure
Have you ever noticed any blood or mucous in your bowel motion?
- No
- Blood
- Mucous

Digestive balance

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Do you burp or bring up wind
Do you get bad breath or body odour
Do you get a white coping on your tongue
Do you get reflux, nausea or vomiting
Do you notice undigested food in your motion
Do you get abdominal pain
Do you get abdominal bloating
Do you get constipation
Do you get loose or unformed motions
Have you had travellers diarrhoea
Does your motion or wind have an odd odour
Does your bottom itch

Allergy symptoms

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Do you get skin rashes
Do you suffer sneezing
Do you suffer nasal congestion
Do you get asthma
Do you get eye irritation or running
Do you get a throat itch or coughing

Vascular symptoms

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Do you get chest pain
Do you get excessively puffed with walking or exertion
Do you get leg pains with walking
Do you get palpitations or are you aware of you heart beat
Do you have to be propped up in bed to breath
Do you get funny turns of loss of vision, passing out, etc
Do your feet feel cold

Thyroid symptoms

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Do you get scalp hair loss
Have you noticed thinning of your body, eyebrow or pubic hair
Do you feel cold more than the people around you
Do you get cold extremities
Do you put on weight easily
Do you get constipated
Do you get dry skin
Do you get fluid retention

Adrenal symptoms

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Do you wake up tired
Do you crave sugar foods
Does your energy vary with food
Does your energy drop in the afternoon
Do you get lightheaded when you stand up
Do you use caffeine for energy
Have you lost capacity to concentrate or multitask
Do you have less energy on days off

Testosterone symptoms

	Never	Occasionally / Mild	Often / Moderate	Always / Severe
Have you noticed a reduction in sexual thought
Have noticed a reduction in facial hair growth
Have you noticed a reduction in urine stream
Have you put on abdominal weight
Do you get recurrent muscle injuries with exercise

Do you smoke?
- Never
- I used to smoke
- I currently smoke
- I used to or currently smoke marijuana
What year did you quite smoking?
How many years did you smoke for?
On average, how many cigarettes did you smoke per day?
On average, how many cigarettes do you smoke per day?
How many years have you smoked for?
Please describe your marijuana use?
Do you use recreational drugs?
- Yes
- No
- I have in the past
Please describe your recreational drug exposure.

Tick what best describes your menstrual cycle:
- I have a regular menstrual cycle
- I have an irregular menstrual cycle
- I have stopped having a menstrual cycle
- I have never had a menstrual cycle
Do you have any of the following symptoms associated before, during or after your menstruation:
Never Occasionally/Mild Often/Moderate Always/Severe
Anxiety
Irritability/mood swings
Forgetfulness
Weight gain >1.5kg
Breast tenderness or swelling
Abdominal bloating
Food cravings
Cramps
Back ache
Acne
Oily skin
Have you taken the oral or implanted contraceptive medication
- Yes, and I am still on this treatment
- Yes, but I am no longer on this treatment
- No
How many years have you been exposed to contraceptive medication
Please enter a number from 0 to 35.
What is your typical or average cycle length in days
Do you experience any of these symptoms of oestrogen deficiency
Never Occasionally/Mild Often/Moderate Always/Severe
Anxiety
Irritability/mood swings
Hot flushes
Vaginal dryness
Night sweats
Reduced sexual desire
Insomnia
Crawling sensation under skin
Leg cramps
How many times have you been pregnant
How many children have you had
Have you had any of the following:
- Miscarraige
- Termination of pregnancy
- Still birth
What age were you when your periods stopped

Sleep quantity

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
Do you have trouble falling asleep
Do you go to bed after midnight
Do you work shift work
Do noises wake you during the night- eg partner, children, neighbours
Do you have to pass urine during the night
Do you sleep less than 6 hours

Sleep quality

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
Do you sleep with your mouth open
Do you snore
Does your snoring bother others
Have you or anyone noticed you stop breathing during the night
Do you get nightmares
Do leg movements interfere with your sleep
Do you wake unrefreshed
Do you sleep on your back
Does pain interfere with your sleep
Do you have high blood pressure
Are you often tired, fatigued or sleep during the day
Do you feel sleepy sitting and reading
Do you feel sleepy watching television
Do you feel sleepy if sitting inactive in a public place
Do you feel sleepy as a passenger in a car for an hour without a break
Do you fall asleep if you lay down in the afternoon
Do you feel sleepy siting and talking with someone
Do you feel sleepy or fall asleep after lunch without alcohol
Do you feel sleepy or fall asleep in traffic for a few minutes while driving

Do you use any of the following sleep supports
- CPAP or APAP
- Chin splint
- Mandibular advancement splint
- Mouth guard

Food last 24hrs - Breakfast time eaten and what was consumed?
Food last 24hrs - Lunch - time eaten and what was consumed?
Food last 24hrs - Dinner - time eaten and what was consumed?
Food last 24hrs - Snacks - time eaten and what was consumed?
Caffeine intake per day- how many of the following drinks do you have each day on average.
None 1 2 3 4 or more
Coffee- count double shots or large as 2
Tea
Coke or Pepsi
Energy drink- eg Red Bull, Mother etc
Coffee milk drinks
Sugar intake per day- how many of the following drinks do you have each day on average.
None 1 2 3 4 or more
Soft drinks
Fruit juices
Flavoured milk
Number of teaspoons of sugar in tea or coffee
Micronutrient score
None 1 2 3 4 or more
How many serves of fruit each day
How many serves of vegetables each day
How many different types of fruit in the last week
How many different types of vegetables in the last week
Allergenic food score
None 1 2 3 4 or more
How many serves dairy products each day
How many serves of wheat products each day
How many serves of soy products each day
Have you ever been diagnosed with:
- Anorexia
- Bulimia
- Coeliac disease
Are you a vegetarian?
- Yes
- No, but I have been in the past
- No
Exercise- Please describe any exercise you did in the last 24 hours and how long you spent doing it.
Relaxation- Please describe any relaxation you did in the last 24 hours and how long you spent doing it.

Your mother's health during her pregnancy carrying you

	Yes	No	Not sure
Low weight gain <8kg
Smoking during pregnancy
Alcohol exposure during pregnancy
Episodes of high alcohol
High stress during pregnancy
Thyroid disease during pregnancy
Gestational diabetes
Dental fillings during pregnancy
House renovation during pregnancy
Infective illness during pregnancy
Threatened miscarraige

Your health and your mother's health during your birth

	Yes	No	Not sure
Caesarian section delivery
Meconium aspiration
Low birth weight <2500gm
High birth weight >4500gm
Foetal distress during labour
Low APGAR scores
Umbilical cord around neck
Excess bleeding and tearing with birth

Your health during your first year of life

	Yes	No	Not sure
Were you breast fed
Did you sleep >12 hours per 24 hour period
Did you suffer nappy rash or thrush infections
Did you suffer eczema or rashes
Did you suffer frequent cols, flu or chest infections
Did you suffer any colic or feeding problems
Were you vaccinated
Did you have any reactions to vaccines

Your health during your childhood

	Yes	No	Not sure
Have you had recurrent tonsillitis
Have you had recurrent middle ear infections
Have you had frequent colds and flu
Have you had multiple courses of antibiotics
Have you had any delayed developmental milestones
Have you had any learning difficulties
Have you had any acne
Have you had growing pains
Do you get depressed or anxious
Have you had stretch marks

Dementia risk

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
Do you suffer poor concentration
Do you get confused in new surroundings
Do you suffer mind fogginess
Do you repeat stories to people without knowing
Are you forgetful
Do you get worried you are getting dementia
Do you get depressed without reason

Osteoporosis risk

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
Have you had fractured bones
Have either of your parents fractured a hip
Do you sit more than 6 hours per day
Do you drink cola type soft drinks
Have you ever taken prednisone medication
Have you used cortisone type skin creams
Have you taken preventative asthma puffers
Do you have rheumatoid arthritis

Bone Density

If you have had a previous bone density DEXA scan, what year was it performed and what was the femoral neck T score (hip result)

PFO risk

	No	Yes
Have you experienced bouts of unexpected fatigue
Do you get unexpected drops of blood pressure
Have experienced loss of vision
Have you experienced any loss of consciousness
Have you experienced illness, dizziness, prolonged fatigue or memory loss after an international flight
Have you experienced altitude sickness
Have you had prolonged fatigue after a virus
Have you ever had a migraine
Do you experience episodes of feeling confused or disoriented
Do you get fatigued after exercise
Do you experience episodes of shortness of breath

Have you been diagnosed with cancer?
- Yes
- No
What type of cancer have you been diagnosed with?
Please describe any treatments you have done for your cancer both medical and natural.
Please list any stressful life events that occurred in the years just preceding your cancer diagnosis?

Emotional resilience

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
Do you have a workplace that you enjoy
Do you contact friends regularly
Do you discuss your feelings with your partner
Do you have enjoyable contact with your family
Do you have strong spiritual values
Do you refer to future goals
Do you have pets that you enjoy
Do you feel your life has purpose

Depression tendency

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
I think about past negative events
I drink alcohol to reduce stressful thoughts or feelings
I dislike who I am
I feel overwhelmed
The happiness of people around me is more important than my own happiness
I get recurrent feelings of not wanting to be here
I make plans in my head for suicide

Anxiety tendency

	Never	Occasionally/ Mild	Often/ Moderate	Always/ Severe
I have recurrent fearful thoughts
I reduce my activity because of feelings of fear or worry
I use alcohol or medications to reduce anxious feelings
My mind has constant chatter
My mind jumps to the worst possible outcomes for any life situation
Worry effects the way I eat

Do you experience headaches or migraines?
- Yes
- No
- I have in the past but not longer get them

During the last 3 months please answer the questions about how many days of function you lost due to your headaches

	0	1	2	3	4	5	6	7	8	9	10 or more
Days of missed work or school
Days your productivity reduced by half or more (not including days above)
Days you did not do household work (eg shopping, parenting, cleaning)
Days your household work productivity was half or less (not counting days above)
Days of missed family, social or leisure activities

On how many days in the last 3 months did you have a headache (If a headache lasted more than 1 day, count each day)
On a scale of 0-10, on average how painful are your headaches? (0=nil, 10=worst pain)
Please enter a number from 0 to 10.

Do you get any of the following symptoms around your headaches

	No	Yes but rarely	Yes, often or always
Bright lights in vision
Flashes of light
Multi coloured lights
Zig-Zag lines
Partial loss of vision
Blurry vision
Speech problems- word finding, slurring
Blindness
Numbness, tingling
Paralysis
Dizziness/ vertigo
Nausea/ vomiting

Do you feel any of the following events were involved in setting off the start of your headache history
No Possibly Yes, very likely
Stressful life event
Neck injury
Motor vehicle accident
Illness
Periods
Pregnancy
Oral contraceptive pill
Hormone replacement therapy
Head trauma
Do you feel any of the following are involved in triggering a headache to occur:
No Possibly Yes, very likely
Specific foods
Caffeine excess
Alcohol
Fatigue
Too little sleep
Chemical fumes - eg perfumes
Computer work
Stress
Menstruation
Sinus or allergy symptoms
Noise
Weather changes

Have you had any of the following toxic exposures:

	No	Possibly or minimal	Yes, I have had recurrent or long term exposure
Amalgam fillings
Root canal fillings
Lead- paints, sinker making, lead lighting, furniture restoration
Playing with mercury
Pesticide/herbicide exposure
Other metal fumes- eg foundaries
Agricultural dip exposure- cattle or sheep
Regular handling of petrol or deisel

Radiation exposure

	Nil	1-2 or minimal	3-6 or mild	7-10 or moderate	Greater than 10 or high exposure
How many xrays did you have prior to the age 20 years
How many CT scans have you had in your life
Estimate many hours do you spend on a mobile phone per week
How many international flights have you done
Have you ever worked with radiation or radioactive material

Please list your current medications and their dose:
Have you suffered a tick bite?
Please list your current supplements and their dose:
Please list any past operations you have had:
For any operations please include the date and location where the procedure was carried out
Please list any past major health issues you have had or been diagnosed with:
Health Prevention Screening
- Sleep test
- Bone density testing (DEXA)
- Pap smear
- Breast check / breast ultrasound
- Mammogram
- Colonoscopy
- Gastroscopy
- Skin check
Please check any health screening assessments have had in the past
Health Prevention Screening
- Sleep test
- Bone density testing (DEXA)
- Prostate check
- Colonoscopy
- Gastroscopy
- Skin check
Please check any health screening assessments have had in the past
Further detail on health screening
For the above health screening you have had, please detail when and where these were performed for each
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Glaucoma
Thyroid disease
Gout
Renal (kidney) disease
Diabetes
Overweight
Stroke
Heart attack, bypass
Heart stent
Sudden cardiac death
Abdominal aneurysm
Peripheral vascular disease, leg amputation
Coeliac Disease
Rheumatoid arthritis
Lupus
Crohn's disease
Ulcerative colitis
Ankylosing spondylitis, HLA - B27
Eczema/Dermatitis
Asthma
Hay fever
Allergy reactions
Osteoporosis
Dementia
Haemochromatosis
Mental health
Depression
Migraine
Breast Cancer
Ovarian Cancer
Bowel Cancer
Lung Cancer
Pancreas Cancer
Melanoma Cancer
Skin Cancer
Other Cancers
Other conditions

Glaucoma
Thyroid disease
Gout
Renal (kidney) disease
Diabetes
Overweight
Stroke
Heart attack, bypass
Heart stent
Sudden cardiac death
Abdominal aneurysm
Peripheral vascular disease, leg amputation
Coeliac Disease
Rheumatoid arthritis
Lupus
Crohn's disease
Ulcerative colitis
Ankylosing spondylitis, HLA - B27
Eczema/Dermatitis
Asthma
Hay fever
Allergy reactions
Osteoporosis
Dementia
Haemochromatosis
Mental health
Depression
Migraine
Prostate Cancer
Testicular Cancer
Bowel Cancer
Lung Cancer
Pancreas Cancer
Melanoma Cancer
Skin Cancer
Other Cancers
Other Conditions

Glaucoma
Thyroid disease
Gout
Renal (kidney) disease
Diabetes
Overweight
Stroke
Heart attack, bypass
Heart stent
Sudden cardiac death
Abdominal aneurysm
Peripheral vascular disease, leg amputation
Coeliac Disease
Rheumatoid arthritis
Lupus
Crohn's disease
Ulcerative colitis
Ankylosing spondylitis, HLA - B27
Eczema/Dermatitis
Asthma
Hay fever
Allergy reactions
Osteoporosis
Dementia
Haemochromatosis
Mental health
Depression
Migraine
Prostate Cancer
Testicular Cancer
Breast Cancer
Ovarian Cancer
Bowel Cancer
Lung Cancer
Pancreas Cancer
Melanoma Cancer
Skin Cancer
Other Cancers
Other Conditions

Glaucoma
Thyroid disease
Gout
Renal (kidney) disease
Diabetes
Overweight
Stroke
Heart attack, bypass
Heart stent
Sudden cardiac death
Abdominal aneurysm
Peripheral vascular disease, leg amputation
Coeliac Disease
Rheumatoid arthritis
Lupus
Crohn's disease
Ulcerative colitis
Ankylosing spondylitis, HLA - B27
Eczema/Dermatitis
Asthma
Hay fever
Allergy reactions
Osteoporosis
Dementia
Haemochromatosis
Mental health
Depression
Migraine
Prostate Cancer
Testicular Cancer
Breast Cancer
Ovarian Cancer
Bowel Cancer
Lung Cancer
Pancreas Cancer
Melanoma Cancer
Skin Cancer
Other Cancers
Other Conditions

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Anxiety
Irritability/mood swings
Forgetfulness
Weight gain >1.5kg
Breast tenderness or swelling
Abdominal bloating
Food cravings
Cramps
Back ache
Acne
Oily skin

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Anxiety
Irritability/mood swings
Hot flushes
Vaginal dryness
Night sweats
Reduced sexual desire
Insomnia
Crawling sensation under skin
Leg cramps

	None	1	2	3	4 or more
Coffee- count double shots or large as 2
Tea
Coke or Pepsi
Energy drink- eg Red Bull, Mother etc
Coffee milk drinks

	None	1	2	3	4 or more
Soft drinks
Fruit juices
Flavoured milk
Number of teaspoons of sugar in tea or coffee

	None	1	2	3	4 or more
How many serves of fruit each day
How many serves of vegetables each day
How many different types of fruit in the last week
How many different types of vegetables in the last week

	None	1	2	3	4 or more
How many serves dairy products each day
How many serves of wheat products each day
How many serves of soy products each day

	No	Possibly	Yes, very likely
Stressful life event
Neck injury
Motor vehicle accident
Illness
Periods
Pregnancy
Oral contraceptive pill
Hormone replacement therapy
Head trauma

	No	Possibly	Yes, very likely
Specific foods
Caffeine excess
Alcohol
Fatigue
Too little sleep
Chemical fumes - eg perfumes
Computer work
Stress
Menstruation
Sinus or allergy symptoms
Noise
Weather changes

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