Get Healthy with Tina

Get Healthy with Tina Woman’s Health Questionnaire

List your current 3 most health concerns

1

2

3

Please take your time to go thru this questionnaire, highlight any symptoms that are relevant to you, if it is severe please put a tick as well. Please print and bring to your consult for further analysis.

Thyroid Function

 Wake up feeling fatigued

 Feeling of cold in fingers and feet

 Low body temperature

 Gain weight easily

 Anxiety/low mood/poor memory

 Goitre bulge or band round neck

 Sparse eyebrows outer 1/3

 Menses heavy/frequent

 Iodine intake, do you use iodiosed salt. Eat fresh fish or seafood

 Do you suffer from breast lumps and ovarian cysts

 Do you carry weight around your upper abdomen

 Tendency to fluid retention

 Puffy under the eyes

 Oily moist skin

 Oily sweat

 Bilateral pain and weakness, fibromyalgia, stiffness

 Slow digestion, constipation

 Poor control of bp and cholesterol

 Sinus and bladder infections

 Infertility

 Periods irregular and heavy

 Humor

 Love fat and sugary foods



Adrenal Function

 fluctuations of body temp with environment

 often slim can’t gain weight

 full eyebrows and thin hair on legs

 Feeling stressed out (poor resilience to stress, tired but wired)

 Over reactive to emotional and physiological stress

 Crave sugar/sweets/salt at 2-4 pm

 Likes salt in foods or savory food (add salt to taste-aldosterone imbalance

 Coffee intake daily

 Sweating, maybe excessive at first, then poor sweating

 Dark circles under eyes

 Irritable or hyperactive bowel, transit time maybe too fast

 Picky fussy eater, IBS, malabsorbtion

 Allergies, over reaction

 Blood sugar issues

 EBV or infectious mononucleosis

 Obsessive compulsive disoreder

 Auto immune conditions

 Menses worse

 Poor sleeping, often wake at 2-4am

 Ligaments sprains and strains,

 Sensitive to meds

 Serious nature, ocd tendencies

 Don’t like change

 Startles easily, anxiety

 Serious nature

 Headaches/migraines

 Dental health, presence of bacterial infections

Describe your body type

 Apple

 Pear

 Hourglass

 Pencil

 Where is the first place you gain weight

Digestion

 Reflux, heartburn, inflammatory bowel conditions

 Frequency of bowel movements Is it complete

 Color of bowel movements

 What does it look like

 Is there food content still obvious

 Tongue coating _____________ scollaping of the tongue yes/no

 How many times a day do you eat

 Do you eat protein 3-4x per day

 How many serves of vegetables per day do you have

 How many serves of fruit a day do you eat

 Do you eat when you are happy or sad

Methylation (b12, folate)

 Intake of green leafy vegetables

 Intake of wholegrain for folate

 Mood disorders, mental illness, alzhiemers

 Cardiovascular disease, increased homocysteine levels,

Blood Sugar levels (high insulin levels, insulin resistance, diabetes, obesity)

 Recent blood sugar levels

 what foods do you crave?

 Lack of pancreatic enzymes

Dysbiosis

 After eating do you experience gas, bloating, indigestion

 Use of antibiotics, in the past_________ recent__________ current ___________

 Do you suffer from vaginal thrush

Liver

 Poor digestion, gall bladder disease, headaches, chemical sensitivity, fatty liver

 Use of alcohol

 Prescription Medications

 Cholesterol Levels, HDL ______ LDL _________ Total ________

 Intake of essential fatty acids __________________________________________

Estrogen/Progesterone

 Prescription meds use of Oral contraceptive pill or progesterone cream

 Do you suffer PMT, bloating, moody, headaches, weight gain, tender breasts

 Average length of menstrual cycle

 How do you describe flow in the first 72 hours

 Pain and cramps

Sleep

 How many hours per night do you sleep

 Bed time _________________ Sleep Time ____________________

 If you wake in the night, can you go back to sleep

 At night do you drop off or do you need to read to go to sleep

Hydration

 Water intake

 Coffee intake

 Do you use salt

Inflammation

 Musculoskeletal disease, rheumatoid arthritis, polyarthritis

 Crohns’s Disease

 Cardiovascular disease, atherosclerosis, stroke, macular degeneration

Acid/alkaline profile

 Osteoporosis

What is the one destructive habbit you have?

What is the one destructive food you enjoy?

Family History of Siblings and Parents.

Client Goals, what would you like to achieve from your treatment.

Thank you for completing this in depth health assessment, I look forward to working with you as you improve your health .

Tina Gale