General Health Questionnaire

Date

Full name

First Name

Last Name

Height

Weight

Age

Gender

Female Male Non-binary Prefer not to say

Date of birth

Eye colour

Address

Street Address

City

State / Province

ZIP / Postal Code

Email

Phone number

Skype username

Family doctor

First Name

Last Name

Family doctor's phone number

Alternative contact number

Blood pressure

First Name

Last Name

Pulse

Respiratory rate

Basal temperature

pH

First Name

Last Name

How many bowel movements do you have a day?

What does your usual diet consist of?

Do your hands and feet get cold?

Yes No

Is it easy to gain weight and hard to lose it?

Yes No

Are your nails ridged, brittle or weak?

Yes No

Do you have varicose or spider veins?

Yes No

Do you have or have you had haemorrhoids or prolapsed organs?

Yes No

Do you get muscle cramps?

Yes No

Do you have an irregular heartbeat?

Yes No

Is your bladder strong or weak?

Strong Normal Weak

Do you have mitral valve prolapse (heart murmur)?

Yes No

Do you get headaches or migraines?

Yes No

Have you ever had a hernia?

Yes No

Do you have osteoporosis?

Yes No

Have you ever had an aneurysm?

Yes No

Do you have scoliosis?

Yes No

Do you get irritated easily?

Yes No

Do you have low energy levels?

Yes No

Do you have symptoms of depression?

Yes No

Did your bone density tests come out low?

Yes No

Do your tests show low calcium levels?

Yes No

Do you have or have you had a goitre?

Yes No

Do you have spinal wear, herniated discs or bone spurs?

Yes No

Have you been diagnosed with Hashimoto's or Riedel's disease? Has a relative?

Yes No

How much do you sweat?

Very little Average amount Quite a lot Excessively

Do your legs tire or cramp when you walk?

Yes No

Do you bruise easily? (parathyroid)

Yes No

Do you get gas after eating?

Yes No

Do you feel food sitting in your stomach?

Yes No

Do you have acid reflux?

Yes No

Do you see undigested food in your stools?

Yes No

Are you thin and find it hard to gain weight?

Yes No

Does food pass straight through you (diarrhoea)?

Yes No

Do you have moles on your body? (adrenal and pancreatic weakness)

Yes No

Section: adrenal glands and pancreas

Are you overweight?

Yes No

Do you have multiple sclerosis, Parkinson's or palsy?

Yes No

Do you have anxiety attacks or feel very anxious?

Yes No

Do you feel excessive shyness or inferiority towards others?

Yes No

Do you have tremors or restless legs?

Yes No

Is your blood pressure high or low?

High Low Normal I do not know

Blood pressure (for example 120/60)

Do you have hypoglycaemia (low blood sugar)?

Yes No

Do you have diabetes (high blood sugar)?

Yes No

Do you have tinnitus (ringing in the ears)?

Yes No

Do you get short of breath or struggle to breathe deeply?

Yes No

Do you have heart arrhythmias?

Yes No

Do you struggle to sleep or have insomnia? (pineal gland)

Yes No

Do you have chronic fatigue syndrome?

Yes No

Have you been diagnosed with Addison's disease or congenital adrenal hyperplasia?

Yes No

Section: inflammation and steroid hormones

Do you have high blood cholesterol?

Yes No

Do you have arthritis, bursitis or other inflammatory problems?

Yes No

Do you have any inflammatory condition ending in 'itis'?

Yes No

Please explain

Do you have low steroid or cortisol levels?

Yes No

Is your menstruation irregular? (pituitary)

Yes No

Do you bleed heavily during menstruation?

Yes No

Do you have or have you had ovarian cysts?

Yes No

Do you have or have you had fibroids?

Yes No

Do you have or have you had endometriosis or atypical cells?

Yes No

Do you have or have you had fibrocystic breasts?

Yes No

Do your breasts hurt, especially during menstruation?

Yes No

Is your sex drive low or excessive?

Low Normal Excessive

Have you had a hysterectomy?

Yes No

If yes, give the date and say whether it was partial or full

Were other organs removed at the same time (for example the gallbladder)?

Yes No

If yes, which other organs?

Have you had a dilation and curettage?

Yes No

Have you had a miscarriage?

Yes No

Have you had difficulty conceiving?

Yes No

Have you taken birth control pills?

Yes No

If yes, for how long?

Are you pregnant at the moment?

Yes No

Do you have prostatitis (frequent urination, especially at night)?

Yes No

If yes, how often do you urinate?

Do you have prostate cancer?

Yes No

If yes, give your PSA level and the date of the test

Do you have testicular enlargement?

Yes No

Is your sex drive low or excessive?

Low Normal Excessive

Do you have erection problems?

Yes No

Do you have premature ejaculation?

Yes No

Do you have gastritis or enteritis?

Yes No

Is your tongue coated (white, yellow, green or brown), especially in the morning?

Yes No

Do you have gastroparesis?

Yes No

Do you have a hiatus hernia?

Yes No

Do you have colitis?

Yes No

Do you have diverticulitis?

Yes No

Do you get or have diarrhoea?

Yes No

Do you get or have constipation?

Yes No

Have you ever had stomach or intestinal ulcers?

Yes No

Do you have or have you had any digestive cancer (stomach, colon, rectum)?

Yes No

If yes, please explain

Do you have Crohn's disease?

Yes No

Do you have problems with gas?

Yes No

General Health Questionnaire

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