General Screening Questionnaire Step 1 of 3 33% General DetailsHiddenForm New Patient Musculoskeletal Supplements Injectables HiddenDoctor's Name:Dr. David JaaDr. Ping JaaDr. Paul PaytonDoctor's Name:Dr. David JaaDr. Ping JaaDr. Paul PaytonHiddenPatient Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Patient Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last HiddenPatient Email Address: Patient Email Address: HiddenAddress Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Address Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country HiddenEmail HiddenPhonePhoneScreeningAllergies: Presenting Problems: Medical History: Surgical History: Current Medications: Current Supplements: Do you drink alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week How many standard drinks containing alcohol do you have on a typical day? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Do you smoke? If yes, how many per day? SymptomsRate each of the following symptoms based upon your health profile for the last 30 days.Point Scale: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe Blank = Not sureDigestive TractNausea or VomitingDiarrhoeaConstipationBloated FeelingBelching or Passing GasHeart BurnIntestinal / Stomach PainEarsItchy EarsEar Aches or InfectionsDrainage From EarRinging in EarsEmotionsMood SwingsAnxiety or NervousnessAnger or AgressivenessDepressionEnergy / ActivityFatigue or SluggishnessApathy or LethagyHyperactivityRestlessnessEyesWatery or Itchy EyesSwollen or Sticky EyelidsBags Under EyesBlurred or Tunnel VisionHeadHeadachesFaintnessDizzinessInsomniaHeartIrregular HeartbeatRapid or Pounding HeartbeatChest PainJoints / MusclesPains or Aches in JointsArthritisStiffness or Limited MovementPain or Aches in MusclesWeakness or TirednessLungsChest CongestionAsthma or BronchitisShortness of BreathDifficulty BreathingMindPoor MemoryConfusion or Poor ComprehensionPoor ConcentrationPoor Physical CoordinationDifficulty Making DecisionsStuttering or StammeringSlurred SpeechLearning DisabilitiesMouth / ThroatChronic CoughingGaggingSore Throat or Voice LossSwollen or Discoloured TongueCanker SoresNoseStuffy NoseSinus ProblemsHayfeverSneezing AttacksSneezing AttacksExcessive Sweating (Nose)SkinAcneHives or RashesHair LossHot FlushesExcessive Sweating (Skin)WeightBinge Eating / DrinkingCraving Certain FoodsExcessive WeightCompulsive EatingWater RetentionUnderweightOtherFrequent IllnessFrequent UrinationGenital Itch or DischargeHiddenTotalAdditional SymptomsPlease mention any other symptoms not listed above. Have you ever been treated with antibiotics? Yes No Have you ever had a yeast infection? Yes No Do you eat or crave sweet foods? Yes No Do you have food allergies? Yes No Have you ever had food poisoning? Yes No Do you or have you consumed alcohol regularly? Yes No Have you ever taken Tagamet or Zantac? Yes No Do you take aspirin, panadeine or other pain killers? Yes No Do you take any other drugs regularly? Yes No Are you often in contact with organic chemicals? Yes No Do you react to strong perfumes, car exhaust, etc? Yes No Do you or have you ever smoked tobacco? Yes No Are you exposed to passive cigarette smoke? Yes No Do you consume caffeine? Yes No Liver Detoxification Test (LDT) Screening QuestionsA certain percentage of patients will experience reactions during the LDT. The reactions include, but are not limited to: shakiness, headaches, nausea, palpitations, light-headedness and sweating. The following questions will help isolate those patients who may experience these reactions.Are you sensitive to food additives like M.S.G.? Yes No Do you react when you consume caffeine? Yes No Do you have a history of liver problems? If yes, describe: Yes No Liver Problems Are you currently taking any drugs? If yes, list: Yes No Drugs Currently Taken CAPTCHA Δ
