Female Questionnaire
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SYMPTOMS: AGING

Q815

Do you have 'age spots' on your skin? Also known as 'liver spots', these are flat brown areas of skin, similar to freckles but larger.
  • No / don't know
  • One or two
  • Fewer than 10
  • 10 or more, but no increase during recent years
  • 10 or more and increasing

Q816

How elastic is your skin? 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) appearance.
  • No / don't know
  • 0-2 seconds (very elastic)
  • 3-4 seconds
  • 5-8 seconds
  • Over 8 seconds (very inelastic)

Q817

How good is your 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? Try to 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)

Q818

Compared to other people of your age, how wrinkled is your skin?
  • About average / don't know
  • I have fewer wrinkles than most
  • I probably have more wrinkles than average
  • I definitely have more wrinkles than others my age

Q819

Have you experienced a reduction in breast fullness and/or increased sagging?
  • Not applicable / don't know
  • No
  • Slight
  • Moderate
  • Severe

Q820

Does your overall 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

Q821

Do you have an overall loss of interest or pleasure in activities that you once enjoyed, due to depression or unknown reasons? If you are still interested but can't enjoy these activities due to fatigue, poor health, lack of time, or stress, answer "No".
  • Don't know / I never had many interests
  • No
  • Slight loss of interest
  • Moderate loss of interest
  • Complete or almost complete loss of interest

SUPPLEMENT, MEDICATION AND DRUG USE

Q822

Do you use multiple vitamin supplements? Only include broad-spectrum preparations, not individual nutrients or specialty combinations such as B-vitamins. "One-a-Day" types are usually low potency; high potency products involve taking several pills a day.
  • None / don't know
  • Minor use in the past only
  • Significant use in the past only
  • Currently using low to moderate doses
  • Currently using large doses

Q823

Have you used any multiple mineral supplements?
  • None / don't know
  • Minor use in the past only
  • Significant use in the past only
  • Currently using low to moderate doses
  • Currently using large doses

Q824

How often do you use aspirin?
  • Don't know
  • Never / less that once a year
  • Occasionally / only when I need it
  • Regularly - several times a month
  • Often - daily or almost daily

Q825

If you take aspirin for pain relief, does it work for you?
  • Not applicable / don't know
  • No
  • Somewhat
  • Definitely

Q826

Have you ever used steroids, in the form of eye drops, by mouth, injections or creams?
  • Don't know
  • No, definitely not
  • Minor - used for less than 2 weeks
  • Moderate - used for up to 3 months
  • Major - used for more than 3 months

Q827

Have you taken other dietary or nutritional supplements within the past year? These include vitamins, minerals, nutraceuticals and others (except hormones) generally found in a health food store, but not always.
  • No / don't know
  • Yes*
* more questions will be asked later

Q828

Have you used antacids or drugs to prevent acid reflux during the past 2 years?
  • Don't know
  • No
  • Yes, but not currently using*
  • Yes, currently using*
* more questions will be asked later

Q829

Have you used antibiotics or antiviral/antifungal/antiparasitic medications within the past 5 years?
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q830

Have you used tranquilizers, sedatives or psychotropic (perception, emotion or behavior-altering) prescription drugs within the past 2 years? These are commonly prescribed for conditions such as Anxiety, Depression, Mania, OCD, etc.
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q831

Have you used any hormones or hormone-altering drugs? Examples include birth control pills, estrogens, progestins/progesterone, testosterone, cortisol/hydrocortisone, Glucophage, melatonin, thyroid hormones.
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q832

Have you used cholesterol-lowering drugs?
  • No / don't know
  • Short-term use in the past only
  • Long-term use in the past only
  • Currently using for 6 months or less
  • Currently using for over 6 months

Q833

Have you used diuretics?
  • Never / don't know
  • Minor use in the past only
  • Significant use in the past only
  • Currently using for up to 6 months
  • Currently using for more than 6 months

Q834

Have you used medications to lower your blood pressure?
  • No / Don't know
  • In the past only
  • Currently using, blood pressure easily controlled
  • Currently using, blood pressure hard to control
  • Currently using, blood pressure not under control

Q835

Do you use any form of laxative, more often than about once per month? This includes stimulant laxatives, bulk laxatives, osmotic laxatives, fecal softeners, fecal lubricants and enemas.
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q836

If you have ever tried coffee enemas, did they provide a noticeable benefit in energy or mental clarity?
  • I haven't tried one / don't know
  • There was no discernable benefit
  • Somewhat
  • Sometimes without doubt
  • Yes, there is always a very pronounced benefit

Q837

Have you been through a heavy metal detoxification program involving metal chelators such as DMPS, DMSA, or EDTA?
  • Don't know
  • No
  • Yes, for a short period of 1 or 2 months
  • Yes, for a period of 3 to 4 months
  • Yes, lasting a total of 5 months or longer

Q838

During the past year, have you used any over-the-counter or prescription pain medications other than aspirin?
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q839

During the past year, have you used any over-the-counter or prescription anti-inflammatory drugs other than aspirin?
  • Don't know
  • No
  • Yes*
* more questions will be asked later

Q840

Have you ever used recreational ("illegal") drugs? Include those that were used for medicinal purposes.
  • No / I would prefer not to say / don't know
  • Yes*
* more questions will be asked later

Q841

Have you taken any other prescription or over-the-counter medications that we have not covered so far? Examples include stimulants, blood thinners, decongestants, anti-nausea drugs, etc.
  • Don't know
  • No
  • Yes*
* more questions will be asked later

PAST MEDICAL PROCEDURES

This section deals with invasive, manipulative or reparative physical procedures that have been carried out on your body.

Q842

Have you received any blood transfusions?
  • No / don't know
  • Yes, one
  • Yes, several

Q843

Have you ever had any type of surgery? For example, transplant surgery, weight loss surgery, tonsillectomy, appendectomy, splenectomy, small bowel resection, colectomy, mastectomy, hysterectomy, vasectomy, prostatectomy.
  • Don't know
  • No
  • Yes*
* more questions will be asked later

LABORATORY VALUES – COMMONLY KNOWN

These values – if known – will help to confirm or rule out certain conditions.  Skip questions you are uncertain of, as well as older tests that are no longer valid.

Q844

Blood Pressure. What is your usual blood pressure without medication? [Top number, systolic]
  • Don't know
  • Under 110 (low)
  • 110 to 129 (normal)
  • 130 to 150 (elevated)
  • Over 150 (very elevated)

Q845

Blood Pressure. What is your usual blood pressure without medication? [Bottom number, diastolic]
  • Don't know
  • Under 70 (low)
  • 70 to 89 (normal)
  • 90 to 100 (elevated)
  • Over 100 (very elevated)

Q846

If you have hypertension (elevated blood pressure), how long has it been elevated? Don't include periods where it was normalized by medication or other means.
  • Not applicable / don't know
  • Less than two years
  • 2 to 6 years
  • 6 to 10 years
  • More than 10 years

Q847

What is your resting pulse rate? While at rest, hold two fingers under your wrist below the base of your thumb until you can feel your pulse. Count the number of beats in 15 seconds and multiply this number by 4.
  • Don't know
  • Under 60 beats per minute
  • 60 to 70
  • 71 to 80
  • Over 80 beats per minute

Q848

Have you had any laboratory or other diagnostic tests in the past year? Examples are blood, urine, stool, hair or saliva analysis; X-rays; scans; biopsies. NOTE: We do not require this information, but it can help to confirm or rule out certain issues.
  • Don't know
  • No tests within the past year
  • Yes, I have had tests within the past year*
* more questions will be asked later

FAMILY HISTORY

Q849

Do you have any knowledge of diseases/conditions that your parents, grandparents, brothers or sisters have had? Answer 'no' if, for example, you were adopted or simply have no idea.
  • No, I can't answer questions about close relatives
  • Yes, I can answer questions about close relatives*
* more questions will be asked later

CHILDHOOD

Q850

Did you ever have Chicken Pox as a child?
  • Don't know
  • Definitely not
  • Yes

Q851

Did you have childhood allergies or signs of allergy such as an "allergic crease" across the nose, runny nose or bags under the eyes?
  • No / don't know
  • Yes, but insignificant
  • Yes, a few minor ones
  • Yes, one or two severe
  • Yes, several severe

Q852

Were you inappropriately physically punished / abused as a child? Do not include sexual abuse here.
  • No / don't know / I deserved it and accept it
  • Mildly - an occasional smack
  • Moderately - regular light physical punishment
  • Occasional severe physical punishment/abuse
  • Severely - frequent hard physical punishment/abuse

Q853

Were you ever molested / sexually abused / raped as a child? Only include incidents that occurred up until the age of 18.
  • No / can't remember / don't know
  • There was occasional molestation
  • Frequent molestation and/or isolated serious abuse
  • Occasional serious abuse over a long period
  • Frequent serious abuse over a long period

Q854

Were you a hyperactive child?
  • No / don't know
  • Somewhat - I was more active than most children
  • Definitely - I was a 'real handful'
  • Severely - I was out of control

Q855

Have you had some or all of the 'required' vaccinations?
  • Don't know
  • I have not been vaccinated at all
  • I have had vaccinations but will not have any more
  • I have had vaccinations and may have more
  • Yes, and I am careful about keeping up-to-date

Q856

Puberty. Compared to your peers (other children of similar age, race and circumstances), did puberty for you begin early or late? The first physical signs of puberty are usually breast and then pubic hair development.
  • It started well over 1 year before my peers
  • It started about a year before my peers
  • It was about average / normal / don't know
  • It started about a year after my peers
  • It started well over 1 year after my peers