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FEMALE QUESTIONNAIRE - PAGE 1    < You are on page 1 of 9 PERSONAL BACKGROUND (Please be patient... we will start with the basics. Later on we will cover all aspects of your health, giving you a chance to tell us about everything.) 1.  Are you currently seeing a doctor about your health concerns? No / don't know Medical doctor (MD, DO) Licensed alternative doctor (ND, DC, OMD etc.) Unlicensed alternative practitioner Both Medical and Alternative doctor(s) 2.  When did you last see a doctor for a health checkup? Don't know More than 5 years ago 2 to 5 years ago 1-2 years ago Within the past year 3.  What is your ethnic background? (Various conditions affect certain groups more than others) Other / don't know Of African descent Asian Caucasian (white) Latin / Hispanic 4.  Have you changed jobs, lost a job or started a new job within the past 2 years? No / over 2 years ago / don't know Within the past 1-2 years Within the past year Within the past 6 months Within the past 3 months 5.  What is your current relationship/marriage status? Not applicable / prefer not to say / don't know Single / never married / no long-term relationship Married / in a long-term committed relationship Divorced / out of long-term committed relationship Widowed 6.  What is the status of your relationship with the person you are married to or living with? Not applicable / don't care / don't know Very troubled Unstable Stable but really needs improvement Stable and good 7.  Have you divorced within the past 2 years? No / over 2 years ago / don't know Within the past 1-2 years Within the past year Within the past 6 months Within the past 3 months 8.  Have you traveled to the tropics within the past 5 years? Don't know No I live in the tropics Yes    More questions later... 9.  Within the past 3 years, have you become sick as a result of being in a country where the food or water is known to be unsafe to consume because of contamination with bacteria or parasites? Don't know No Yes    More questions later... 10.  Have you been infected with any form of parasite within the last 2 years? This includes worms, protozoa (such as Giardia), and amoeba, but not yeast, bacteria, or viruses. Don't know No Yes    More questions later... 11.  How many hours do you work each week? 'Work' is defined as tasks which, given the choice, you would rather not do - this can include childcare, housework, studying and so on. I don't work / don't know Under 35 35 to 47 48 to 60 Over 60 12.  How far north or south of the equator do you spend most of your time? If unsure, enter a note below or see latitudes of major cities (close that window to return here). Don't know / can't work it out 0-23° (The tropics) 24-40° (U.S. south of Great Lakes; Australia) 41-56° (Northern U.S.; Canada; Europe) Over 56° (Scotland; Scandinavia; Alaska) Add any additional information here for the questions above: Please mention the question number(s) if possible.   HABITS / ACTIVITIES / TENDENCIES 13.  Approximately how much moderately strenuous AEROBIC exercise do you manage to get each week? Examples would include a brisk walk, running, bicycling or swimming. Don't know Less than 2 hours total each week 2-5 hours total each week 5-7 hours total per week Over 7 hours total per week 14.  Approximately how much moderately strenuous NON-AEROBIC (anaerobic - weight training, circuit training or other weight-bearing) exercise do you manage to get each week? Don't know Less than 2 hours total per week 2-5 hours total per week 5-7 hours total per week Over 7 hours total per week 15.  Aside from specific exercise sessions, for approximately how many hours each week are you strenuously active? This includes activities/jobs that involve lifting/carrying heavy objects, digging, running etc. Don't know None 1 to 5 6 to 10 More than 10 16.  If you are not getting as much exercise as you should (at least 4-5 hours of aerobic exercise per week), what is the reason for this? Work-related activity involving raised heart rate and sweating qualifies as exercise. Not applicable (I do exercise enough) / don't know I just don't feel like it I don't have the time Physical problems prevent me Disease / illness prevents me 17.  When you exercise (run, walk fast, cycle, etc.), do you easily get a stitch in your side? Don't know No, never Rarely Regularly, but under half the time Most of the time 18.  How long does it take you to recover from moderate exertion? Moderate exertion is defined as any activity that causes an increase in pulse / breathing / sweating for at least 10 minutes. Don't know Under an hour Several hours Most of the day 24 hours or more 19.  Excessive exercise. Would friends say that you exercise compulsively, or that you train too much? No / don't know Some do Yes, definitely 20.  Do you practice yoga? Never / don't know Once per month or less Once per week or less A few times per week At least daily 21.  Second-hand smoke. Within the last eight years, roughly how much time have you spent in smoke-filled environments? Heavy exposure is defined as being in a room with visible smoke/haze for more than 4 hours per day. Don't know None / minimal 1-4 years of light exposure 5-8 years of light exposure or 1-4 years heavy 5-8 years of heavy exposure 22.  Have you ever used tobacco products (cigarettes, cigars, chewing tobacco, etc.) on a regular basis? Don't know No Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: GENERAL 23.  Bodily coordination. How good is your control over your physical movements, for example picking up something very small or catching a ball? Very poor - I'm very clumsy / drop things Somewhat worse than average Average / don't know Better than average Excellent 24.  Have you had neuritis (inflammation of nerves) or a neuropathy (a condition of nerve degeneration)? Never had it / don't know Probably had it / minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 25.  Do you ever feel dizzy/faint when standing up or sitting up suddenly? Don't know Never / very rarely Occasionally - several times per year Often - several times per month Always or almost always 26.  Do you ever feel dizzy or faint for reasons unrelated to standing or sitting up suddenly? Don't know Never / very rarely Occasionally - several times per year Often - several times per month Always or almost always 27.  Do you ever experience vertigo? Don't know Never / very rarely Occasionally - several times per year Often - several times per month Daily or almost daily 28.  Do your hands and/or feet tend to be...? Usually cold Sometimes cold Normal / don't know Sometimes warm Usually warm 29.  How well do you tolerate other people? I am not critical; I tolerate/forgive easily I occasionally have difficulty tolerating people I'd say I'm about average / don't know I am sometimes over-critical I tend to be critical, unforgiving, quick to judge 30.  What is your level of pain tolerance generally? Very poor pain tolerance Poor pain tolerance Average / don't know Moderate pain tolerance High pain tolerance 31.  Sense of humor. Do you have...? Very little / none Some I'd say I'm about average / don't know Better than average Over the top 32.  Inflammation. Have you suffered from one or more inflammations that seem chronic or recurring? No / don't know Minor, for one condition Minor, for more than one condition Major, for one condition Major, for more than one condition 33.  How easy do you find it to relax? Very difficult Mildly difficult Average / don't know Fairly easy I am very relaxed by nature 34.  Do you tend to recover slowly from colds and / or feel weak afterwards? Don't know No, I generally recover fully within a day or two Sometimes Often Always 35.  Do you have a sensation of general weakness? No / don't know Mild, sometimes present Moderate Serious Severe, always present 36.  Activity. Are your physical motions...? Slow / heavy Average / don't know Quick / efficient / light 37.  Have you had a problem with fatigue or becoming too easily exhausted? Don't know No, never Yes, in the past only Yes, it is a current or ongoing problem More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: AGING 38.  Do you have brown 'age spots' on your skin? Also known as 'liver spots', these are larger than and different from freckles. No / don't know One or two Fewer than 10 10 or more, but not increasing in number 10 or more and increasing 39.  Skin Elasticity. Pinch a large section of skin on the back of your hand, holding firmly for 5 seconds. Release and count the number of seconds for the pinched skin to return to its normal (totally flat - don't cheat!) appearance. No / don't know 0-2 seconds (very elastic) 3-4 seconds 5-8 seconds Over 8 seconds (very inelastic) 40.  Balance. Stand on a hard surface with feet together. Close your eyes and lift your dominant foot about six inches (15cm). How long can you stand on your other foot without falling or opening your eyes? For better accuracy, do this 3 times and average. I can't do this test / I am injured / don't know Under 4 seconds (poor balance) 4-9 seconds 10-25 seconds Over 25 seconds (very good balance) 41.  Has your ability to walk declined within the past year for unknown reasons? No change / reason known / don't know A little, but I can still walk unaided I need some assistance I need a lot of assistance I can no longer walk at all 42.  Has your ability to use one or both of your arms declined within the past year for unknown reasons? No change / reason known / don't know Yes, a little Yes, significantly I have lost or almost lost all arm function 43.  Are you concerned about wrinkles in your skin? No / don't know Moderately Very 44.  Have you experienced a reduction in breast fullness and/or increased sagging? Not applicable / don't know No Mild Moderate Major 45.  Does your health seem to be declining as you age? No more than normal / don't know No, not at all Slightly - minor issues are turning up Moderately - I am definitely having more problems Seriously - my health is declining at a rapid rate 46.  Have you had a stroke-type event? No / don't know Mini-stroke (TIA or brief disturbance) More than one mini-stroke An actual stroke A severe stroke or more than one 47.  Do you have an overall loss of interest or pleasure in activities that you once enjoyed? Don't know No Slightly Moderately Completely or almost completely Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: FOOD: GENERAL 48.  Do you need to get up and eat during your hours of sleep? Don't know No I eat a little occasionally, less than once a week I eat a lot occasionally or a little regularly I eat a lot regularly, several times per week 49.  Do you make a point of avoiding aspartame? It is commonly found in low-calorie drinks and foods. No / don't know Sometimes I generally try to avoid it I try very hard to avoid it I absolutely avoid it 50.  Are you bothered by eating food containing monosodium glutamate (MSG)? Typical reactions might include headaches, double vision, diarrhea or dizziness. Don't know Definitely not Mildly Moderately Severely 51.  How do you react to spicy foods? Poorly Normal tolerance / don't know High tolerance 52.  Are you lactose intolerant? Don't know No, I know for sure that I am not Moderately, resolved by lactase / consuming less Severe problem and must strictly avoid dairy 53.  How often do you need to eat each day to maximize your well-being and productivity? Under three meals with no/light snacks Three meals with no snacks Three meals and occasional snacks / don't know Three meals with consistent snacking At least three meals and large snacks 54.  Is your appetite generally...? Very weak - I eat infrequently and small amounts Weak Average / don't know Strong Very strong - I rarely miss an opportunity to eat 55.  Have you lost your appetite suddenly within the past 4 weeks? I lost it more than 4 weeks ago / don't know No, my appetite is fine Yes, but it has now returned Yes, 2-4 weeks ago and it has not returned Yes, under 2 weeks ago and it has not returned 56.  Have you been on any weight-loss diets within the past 5 years? No / don't know Yes    More questions later... 57.  Have you experienced the eating disorder known as anorexia? Don't know No In the past only, not a current problem Current moderate problem Current major problem 58.  Have you experienced the eating disorder known as bulimia? Don't know No In the past only, not a current problem Current moderate problem Current major problem 59.  Is your stomach upset by greasy food? No / don't know Mildly Moderately Seriously Severely 60.  Do you have any digestive problem when eating garlic or onions? Don't know No Yes, trouble with garlic Yes, trouble with onions Trouble with both Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: FOOD: INTAKE These questions give us a rough idea of your diet. Don't worry if you can't get these answers exactly right - simply answer to the best of your ability. 61.  How often do you consume tofu, soybean curd, soy milk or cooked soybean products? Never / don't know Once per month or less Once per week or less A few times per week At least daily 62.  Do you consume dairy (milk/cheese/cream) products? Never / don't know Once per week or less 2-6 times per week Some every day A lot / more than once daily 63.  Estimate how much food you consume that has been fortified with calcium. Common examples are orange juice, soy milk, milk and other dairy products. Don't know None / rarely Under one cup (250ml) per day 1-3 cups per day At least three cups (750ml) each day 64.  Estimate how often you consume iodine-containing food. The most common dietary sources of iodine are seaweeds and iodized salt. Don't know Never / rarely / I don't make a point of it A few times per week Daily or almost daily 65.  Do you consume processed meats, such as hot dogs, sausages, bacon, jerky, smoked ham or luncheon meats? Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily 66.  Do you consume fast food? Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily 67.  Aside from fast food, how often do you consume deep-fried foods? Never / don't know Once per week or less 2-3 times per week 4-7 times per week A lot / more than once daily 68.  Aside from fast food, roughly how often do you consume grilled, broiled or barbecued red meat or chicken? Don't know Never / no more than once per year Once per month or less 2-4 times per month More than 4 times per month 69.  On average, how many DAILY servings of fruits and vegetables do you eat? A serving is about the size of a tennis ball, or half a cup (125ml) for most fruits and vegetables. Include everything except potatoes and grains such as rice. Don't know None / under two About 2 to 3 About 4 to 5 More than 5 70.  Roughly how many WEEKLY servings of LEGUMES (peas, beans, lentils, peanuts, soy etc.) do you eat? A serving is about the size of a tennis ball, or half a cup (125ml). Don't know None / under two About 2 to 3 About 4 to 5 More than 5 71.  Approximately how much dark leafy green vegetable or broccoli do you eat? A serving is about the size of a tennis ball, or half a cup (125ml). Don't know None / less than one serving per week Less than one serving per day 1-3 servings per day 3 or more servings per day 72.  Refined sugar. Estimate how often you consume sugar-containing snacks (cookies, candy bars...), desserts (cakes, puddings...) or other servings of at least one tablespoon of sugar (for example in cereal, coffee...)? Do not include soft drinks here. Never / rarely / don't know About once per week About 2-3 times per week Roughly daily or almost daily A lot / more than once per day 73.  Hydrogenated oils / fats. How often, on average, do you consume them, not distinguishing good oil from bad? They are often found in margarines, cakes, biscuits, french fries, chips, and sweets for example. Never On rare occasions / I try very hard to avoid them A few times per week About once a day More than once daily (average diet) / don't know 74.  Estimate how much unheated flax or hemp oil, non-hydrogenated canola oil or fish oil you consume per week. A 'unit' can be: 1 tbsp flax oil, 3 tbsp flax seed, 3 tbsp hemp oil, 1/3 cup hemp seeds, 1/2 cup walnuts, 4 tbsp canola oil OR 1gm fish oil. None / rarely / don't know One unit per week 2-3 units per week 4-10 units per week More than 10 units per week 75.  How many tablespoons of safflower, sunflower, corn or cottonseed oil do you consume per week? NOTE: "All-purpose vegetable oil" is commonly a mixture of corn and cottonseed oil - look at the label. None / rarely 1-3 per week 4-7 per week / don't know 8-14 per week Definitely more than 14 per week 76.  Approximately how many tablespoons of olive oil do you consume weekly? Don't know None / negligible 1-3 4-9 10 or more tablespoons 77.  How many servings of fish do you consume on average per month? None / rarely / don't know One Two Three to four Five or more 78.  Do you eat refined white flour products, for example French, Italian or other white bread, bagels, pasta etc.? Don't know Never No more than 3 times per week 4-7 times per week A lot / more than once daily 79.  Salt. How much added salt (salt that is not already in the food) do you consume on average? None A little Average / don't know Above average A lot - I usually add salt and enjoy salted foods 80.  Being honest with yourself, do you feel that the amount of calories you are consuming is...? Definitely not enough Probably not enough About right / don't know Probably too many Definitely too many 81.  How would you rate your overall fat / oil intake from food and supplements? Extremely low Moderately low Average / don't know Moderately high Very high 82.  On average, approximately how many raw egg whites do you consume in a week? Don't know None at all Up to 2 per week About 3 to 7 per week 8 or more per week 83.  Very approximately, how many cooked egg whites do you consume in a week? This includes any egg whites hidden in prepared dishes, baked goods and products like mayonnaise. I have no idea! None, in any form Up to 2 per week About 3 to 7 per week 8 or more per week 84.  Very approximately, how many raw or cooked egg yolks do you consume in an average week? This includes any egg yolks hidden in prepared dishes, baked goods and products like mayonnaise. I have no idea! None, in any form Up to 2 per week About 3 to 7 per week 8 or more per week 85.  How often do you consume garlic? Never / don't know Once per month or less Once per week or less A few times per week At least daily Add any additional information here for the questions above: Please mention the question number(s) if possible.