SYSTEMS
CONSULTING
REGISTER
TESTIMONIALS
HOME
CONTACT PE
CONTACT MASH
HOLISTIC PET CARE
COSMETIC ACUPUNCTURE
MEDICAL ACUPUNCTURE
E.A.V. TESTING
B.T.A. LAB ANALYSIS
Log in
Please enter the password to view this page
Register
Not a Member yet?
Register here
.
Essential Heath Questionnaires
Please complete each section of the questionnaire below and add to cart.
You will receive an e-mailed delivery of Dr. Stewart's Consultation within 7 days.
Section 1:
Digestion
Select One
Never
Rarely
Time to Time
Often
Lower bowel gas several hours after eating
Select One
Never
Rarely
Time to Time
Often
Excessive belching/burping
Select One
Never
Rarely
Time to Time
Often
Burning stomach sensation, eating relieves
Select One
Never
Rarely
Time to Time
Often
Bad breath
Select One
Never
Rarely
Time to Time
Often
Coated tongue
Select One
Never
Rarely
Time to Time
Often
Alternating diarrhea/constipation
Select One
Never
Rarely
Time to Time
Often
Indigestion 1-4 hrs. after eating
Select One
Never
Rarely
Time to Time
Often
Have pets e.g., dogs, cats, farm animals, etc.
Select One
Never
Rarely
Time to Time
Often
Carbonated drinks 3+ per week?
Select One
Never
Rarely
Time to Time
Often
Rectal itching
Select One
Never
Rarely
Time to Time
Often
Difficult bowel movements
Select One
Never
Rarely
Time to Time
Often
Can’t gain weight
Select One
Never
Rarely
Time to Time
Often
Ulcers? / Colitis? / Gastritis?
Select One
Never
Rarely
Time to Time
Often
International travel
Select One
Never
Rarely
Time to Time
Often
Stomach bloating after eating
Select One
Never
Rarely
Time to Time
Often
Stomach/intestinal cramping/diarrhea
Section 2:
Sugar Handling
Select One
Never
Rarely
Time to Time
Often
Afternoon headaches
Select One
Never
Rarely
Time to Time
Often
Abnormal craving for sweets or snacks
Select One
Never
Rarely
Time to Time
Often
Get “shaky” if hungry
Select One
Never
Rarely
Time to Time
Often
Thirsty much of the time
Select One
Never
Rarely
Time to Time
Often
Faintness if meals delayed
Select One
Never
Rarely
Time to Time
Often
History of diabetes
Select One
Never
Rarely
Time to Time
Often
Heart palpitates if meals missed or delayed
Select One
Never
Rarely
Time to Time
Often
Excessive frequent urination
Select One
Never
Rarely
Time to Time
Often
Eat when nervous
Select One
Never
Rarely
Time to Time
Often
Blurred vision/failing eyesight
Select One
Never
Rarely
Time to Time
Often
Awaken after few hours of sleep
Select One
Never
Rarely
Time to Time
Often
Breath smells sweet
Select One
Never
Rarely
Time to Time
Often
Hard to get back to sleep
Select One
Never
Rarely
Time to Time
Often
Tingling, numbness, prickling sensation in
Select One
Never
Rarely
Time to Time
Often
Crave candy or coffee in afternoon
Section 3:
Cardiac
Select One
Never
Rarely
Time to Time
Often
Bruise easily, “black & blue” spots
Select One
Never
Rarely
Time to Time
Often
Abnormal craving for sweets or snacks
Select One
Never
Rarely
Time to Time
Often
Sigh frequently
Select One
Never
Rarely
Time to Time
Often
Numbness in extremities
Select One
Never
Rarely
Time to Time
Often
Aware of “breathing heavily"
Select One
Never
Rarely
Time to Time
Often
Tendency to anemia
Select One
Never
Rarely
Time to Time
Often
Open window in closed room
Select One
Never
Rarely
Time to Time
Often
Tension or tightness under breastbone
Select One
Never
Rarely
Time to Time
Often
Susceptible to colds & fevers
Select One
Never
Rarely
Time to Time
Often
Blushing with no apparent cause
Select One
Never
Rarely
Time to Time
Often
Swollen ankles, worse at night
Select One
Never
Rarely
Time to Time
Often
Black stool (no iron supplementation)
Select One
Never
Rarely
Time to Time
Often
Muscle cramps, worse during night
Select One
Never
Rarely
Time to Time
Often
Poor concentration
Select One
Never
Rarely
Time to Time
Often
Shortness of breath on exertion
Select One
Never
Rarely
Time to Time
Often
Slurred speech
Select One
Never
Rarely
Time to Time
Often
Nosebleeds
Select One
Never
Rarely
Time to Time
Often
Headaches
Select One
Never
Rarely
Time to Time
Often
Ringing in the ears
Select One
Never
Rarely
Time to Time
Often
Weakness/fatigue
Select One
Never
Rarely
Time to Time
Often
Heart palpitations
Select One
Never
Rarely
Time to Time
Often
Out of breath frequently e.g., going up stairs
Select One
Never
Rarely
Time to Time
Often
Dull pain in chest or radiating into left arm
Select One
Never
Rarely
Time to Time
Often
Nervousness
Section 4:
Liver & Gall Bladder
Select One
Never
Rarely
Time to Time
Often
Pain under right side of rib cage
Select One
Never
Rarely
Time to Time
Often
Laxatives used
Select One
Never
Rarely
Time to Time
Often
Frequent skin rashes
Select One
Never
Rarely
Time to Time
Often
History of gall bladder attacks or gallstones
Select One
Never
Rarely
Time to Time
Often
Bitter metallic taste in mouth in morning
Select One
Never
Rarely
Time to Time
Often
History of hepatitis
Select One
Never
Rarely
Time to Time
Often
Bowel movements painful or difficult
Select One
Never
Rarely
Time to Time
Often
History of jaundice
Select One
Never
Rarely
Time to Time
Often
Low energy, weakness, exhaustion
Select One
Never
Rarely
Time to Time
Often
Sneezing attacks
Select One
Never
Rarely
Time to Time
Often
Upset from greasy/fatty foods
Select One
Never
Rarely
Time to Time
Often
Itchy skin, worse at night
Select One
Never
Rarely
Time to Time
Often
Bruises easily
Select One
Never
Rarely
Time to Time
Often
Dry flaky skin, hair
Select One
Never
Rarely
Time to Time
Often
Frequent headaches
Select One
Never
Rarely
Time to Time
Often
General feeling of poor health
Select One
Never
Rarely
Time to Time
Often
Stools light colored
Select One
Never
Rarely
Time to Time
Often
Aching muscles
Select One
Never
Rarely
Time to Time
Often
Pain between shoulder blades
Select One
Never
Rarely
Time to Time
Often
Swollen feet and/or legs
Section 5:
Thyroid
Select One
Never
Rarely
Time to Time
Often
Impaired hearing
Select One
Never
Rarely
Time to Time
Often
Slow pulse, below 65
Select One
Never
Rarely
Time to Time
Often
Decrease in appetite
Select One
Never
Rarely
Time to Time
Often
Cold hands and feet
Select One
Never
Rarely
Time to Time
Often
Ringing in ears
Select One
Never
Rarely
Time to Time
Often
Gains weight easily
Select One
Never
Rarely
Time to Time
Often
Constipation
Select One
Never
Rarely
Time to Time
Often
Weight gain around hips
Select One
Never
Rarely
Time to Time
Often
Puffy hands/face
Select One
Never
Rarely
Time to Time
Often
Outer third of eyebrow thinning
Select One
Never
Rarely
Time to Time
Often
Tired/sluggish
Select One
Never
Rarely
Time to Time
Often
“Emotional”
Select One
Never
Rarely
Time to Time
Often
Miscarriages
Select One
Never
Rarely
Time to Time
Often
Flush easily
Select One
Never
Rarely
Time to Time
Often
Infertility
Select One
Never
Rarely
Time to Time
Often
Night sweats
Select One
Never
Rarely
Time to Time
Often
Mental sluggishness/forgetfulness
Select One
Never
Rarely
Time to Time
Often
Hair loss
Select One
Never
Rarely
Time to Time
Often
Headache upon rising; wears off during day
Section 6:
Bone Development
Select One
Never
Rarely
Time to Time
Often
Hip and joint pain
Select One
Never
Rarely
Time to Time
Often
Bone loss/osteoporosis in family
Select One
Never
Rarely
Time to Time
Often
Receding gums and/or dental cavities
Select One
Never
Rarely
Time to Time
Often
Crunching, creaking joints
Select One
Never
Rarely
Time to Time
Often
Tendency towards slouching/weak
Section 7:
Environmental
Select One
Never
Rarely
Time to Time
Often
Exposure to fumes e.g., paint, salon, car
Select One
Never
Rarely
Time to Time
Often
Skin disorders e.g., psoriasis, eczema
Select One
Never
Rarely
Time to Time
Often
Use pesticides on garden
Select One
Never
Rarely
Time to Time
Often
Loss of hair
Select One
Never
Rarely
Time to Time
Often
Live near power lines/high tension wires
Select One
Never
Rarely
Time to Time
Often
Hormone disorders
Select One
Never
Rarely
Time to Time
Often
Have mercury amalgams (silver) in mouth
Select One
Never
Rarely
Time to Time
Often
History of cancer/personal or familial
Section 8:
Muscle & Ligament
Select One
Never
Rarely
Time to Time
Often
Muscle aches, stiffness, cramping and pains
Select One
Never
Rarely
Time to Time
Often
Fatigue, sluggishness
Select One
Never
Rarely
Time to Time
Often
Chiropractic adjustments don’t hold
Select One
Never
Rarely
Time to Time
Often
Upper or lower back pain
Select One
Never
Rarely
Time to Time
Often
Whiplash and/or ligamental trauma/strain
Select One
Never
Rarely
Time to Time
Often
Stiff neck and shoulders
Section 9:
Adrenals
Select One
Never
Rarely
Time to Time
Often
Low blood pressure
Select One
Never
Rarely
Time to Time
Often
Crave salty foods
Select One
Never
Rarely
Time to Time
Often
Chronic fatigue
Select One
Never
Rarely
Time to Time
Often
Feeling un refreshed upon awakening
Select One
Never
Rarely
Time to Time
Often
Low energy, lack of stamina
Select One
Never
Rarely
Time to Time
Often
Allergies
Select One
Never
Rarely
Time to Time
Often
General malaise, unhappiness
Select One
Never
Rarely
Time to Time
Often
Exhaustion– muscular & nervous
Select One
Never
Rarely
Time to Time
Often
Tendency to hives
Select One
Never
Rarely
Time to Time
Often
Respiratory disorders
Select One
Never
Rarely
Time to Time
Often
Arthritic tendency
Select One
Never
Rarely
Time to Time
Often
Swollen ankles
Select One
Never
Rarely
Time to Time
Often
Excessive perspiration
Select One
Never
Rarely
Time to Time
Often
Dizzy when stand up “too fast”
Select One
Never
Rarely
Time to Time
Often
Colds/flu often
Select One
Never
Rarely
Time to Time
Often
Irritable
Select One
Never
Rarely
Time to Time
Often
Weakness after illness
Select One
Never
Rarely
Time to Time
Often
Bright lights irritate
Select One
Never
Rarely
Time to Time
Often
Dark circles under the eyes
Section 10:
Female
Select One
Never
Rarely
Time to Time
Often
Painful menses
Select One
Never
Rarely
Time to Time
Often
Lumpy breasts/worse at menses
Select One
Never
Rarely
Time to Time
Often
Premenstrual tension
Select One
Never
Rarely
Time to Time
Often
Have taken birth control pills
Select One
Never
Rarely
Time to Time
Often
Very easily fatigued
Select One
Never
Rarely
Time to Time
Often
Menopause, hot flashes, etc.
Select One
Never
Rarely
Time to Time
Often
Depressed feeling
Select One
Never
Rarely
Time to Time
Often
Menses scanty or irregular
Select One
Never
Rarely
Time to Time
Often
Menstruation excessive and prolonged
Select One
Never
Rarely
Time to Time
Often
Acne, worse at menses
Select One
Never
Rarely
Time to Time
Often
Painful breasts (monthly)
Select One
Never
Rarely
Time to Time
Often
Vaginal discharge/yeast, etc.
Section 11:
Male
Select One
Never
Rarely
Time to Time
Often
Tired too easily
Select One
Never
Rarely
Time to Time
Often
Feeling of incomplete bowel evacuation
Select One
Never
Rarely
Time to Time
Often
Urination difficult
Select One
Never
Rarely
Time to Time
Often
Prostate trouble
Select One
Never
Rarely
Time to Time
Often
Night urination frequent
Select One
Never
Rarely
Time to Time
Often
Leg nervous at night
Select One
Never
Rarely
Time to Time
Often
Pain on inside of legs or heel
Select One
Never
Rarely
Time to Time
Often
Diminished sex drive
Section 12:
Lung
Select One
Never
Rarely
Time to Time
Often
Chronic cough
Select One
Never
Rarely
Time to Time
Often
Bronchitis (frequent)
Select One
Never
Rarely
Time to Time
Often
Pain around ribs
Select One
Never
Rarely
Time to Time
Often
Infections settle in lungs
Select One
Never
Rarely
Time to Time
Often
Shortness of breath
Select One
Never
Rarely
Time to Time
Often
Sensitive to smog
Select One
Never
Rarely
Time to Time
Often
Chest pain
Select One
Never
Rarely
Time to Time
Often
Asthma
Select One
Never
Rarely
Time to Time
Often
Difficulty breathing Post nasal drip
Select One
Never
Rarely
Time to Time
Often
Wheezing
Select One
Never
Rarely
Time to Time
Often
Post nasal drip
Select One
Never
Rarely
Time to Time
Often
Smoker
Select One
Never
Rarely
Time to Time
Often
Sinus and nasal congestion
Select One
Never
Rarely
Time to Time
Often
Chronic lung congestions
Select One
Never
Rarely
Time to Time
Often
Coughing up phlegm
Select One
Never
Rarely
Time to Time
Often
Breathes through mouth
Select One
Never
Rarely
Time to Time
Often
Coughing up blood
Select One
Never
Rarely
Time to Time
Often
Shallow breather
Section 13:
Immune
Select One
Never
Rarely
Time to Time
Often
Throat infections
Select One
Never
Rarely
Time to Time
Often
Cough with mucus
Select One
Never
Rarely
Time to Time
Often
Poor wound healing
Select One
Never
Rarely
Time to Time
Often
Swollen tongue
Select One
Never
Rarely
Time to Time
Often
Slow to recover from colds or flu
Select One
Never
Rarely
Time to Time
Often
Dark areas under the eyes/cheeks
Select One
Never
Rarely
Time to Time
Often
Gets boils or sties
Select One
Never
Rarely
Time to Time
Often
Sore throat
Select One
Never
Rarely
Time to Time
Often
Swollen lymph glands
Select One
Never
Rarely
Time to Time
Often
Post nasal drip
Select One
Never
Rarely
Time to Time
Often
Catch colds or flu easily
Select One
Never
Rarely
Time to Time
Often
Ear aches and infections
Select One
Never
Rarely
Time to Time
Often
Bumpy skin on arms
Select One
Never
Rarely
Time to Time
Often
Herpes/cold sores
Select One
Never
Rarely
Time to Time
Often
Inflamed or bleeding gums
Section 14:
Kidney
Select One
Never
Rarely
Time to Time
Often
Frequent urination
Select One
Never
Rarely
Time to Time
Often
Strong smelling urine
Select One
Never
Rarely
Time to Time
Often
Rose-colored (bloody) urine
Select One
Never
Rarely
Time to Time
Often
Mild back pain
Select One
Never
Rarely
Time to Time
Often
Dripping after urination
Select One
Never
Rarely
Time to Time
Often
Interrupted urine stream
Select One
Never
Rarely
Time to Time
Often
Difficulty passing urine
Select One
Never
Rarely
Time to Time
Often
Tingling in joints
Select One
Never
Rarely
Time to Time
Often
Cloudy urine
Select One
Never
Rarely
Time to Time
Often
Joint and muscle pain/cramping
Select One
Never
Rarely
Time to Time
Often
Rarely need to urinate
Select One
Never
Rarely
Time to Time
Often
Can’t hold urine
Select One
Never
Rarely
Time to Time
Often
Frequent bladder infections
Select One
Never
Rarely
Time to Time
Often
Dark circles under eyes
Select One
Never
Rarely
Time to Time
Often
Painful/burning when urinating
Select One
Never
Rarely
Time to Time
Often
Frequently urinate small amounts
Select One
Never
Rarely
Time to Time
Often
Urination when cough or sneeze
Section 15:
Extended Information
List below all medications that you are currently taking:
List below how often you take or have taken antibiotics:
List below any allergies that you have:
List below any reactions that you have had to vaccinations:
Drink 6-8 glasses of water daily
Experiencing bone loss or osteoporosis
Root canals
Hormone replacement medications
Wisdom teeth were/are impacted
Smoker
Crowns/bridges
Diagnosed or history of Candida
How many silver amalgams do you have in your mouth?
Diagnosed for parasites
List below any other dental problems:
29.95
www.pureenergyforlife.com
© 2008 Dr. Stewart Enterprises
