Comprehensive Wellness Survey

The Medical Sanctuary Holistic Medical Centre

Select the number which best describes the frequency of your symptoms. If you do not know the answer to the question, leave it blank. When you are finished, please add the number of points in each section and enter the number on the Total Points line. The score for YES is the number inside the parenthesis ( ).

0 = never or rarely, 1= twice a week or less, 2 = three to six times a week, 3 = daily or several times a day

Section A: DIGESTION AND DYSBIOSIS

1. Excessive belching, burping and/or bloating. 0 1 2 3

2. Gas immediately after meals 0 1 2 3

3. Indigestion and fullness lasts 2-4 hours after eating 0 1 2 3

4. Excessive gas and bloating 0 1 2 3

5. Abdominal cramping, aches and pains 0 1 2 3

6. Specific foods and beverages aggravate 0 1 2 3

7. Roughage or fibre cause constipation 0 1 2 3

8. Alternating diarrhoea/constipation 0 1 2 3

9. Stool – yellowish, foul smelling 0 1 2 3

10. Stool – undigested food present 0 1 2 3

11. Painful, difficult straining during bowel movements 0 1 2 3

12. Bright red blood following bowel movement 0 1 2 3

13. Anal itching 0 1 2 3

14. Crave sugar/breads/sweets or alcohol 0 1 2 3

15. Frequent or urgent urination 0 1 2 3

16. Bad breath and/or body odour 0 1 2 3

17. Antibiotic use 4 or more times/year N Y (3)

18. Long term antibiotic use, greater than 1 month N Y (5)

19. On birth control pill more than 2 years N Y (4)

20. Athlete’s foot, ringworm or any chronic fungal infections of the skin or nails? N Y (4)

Total points ________

Section B: LIVER FUNCTION & DETOXIFICATION

1. Fatty foods cause indigestion 0 1 2 3

2. Feel restless, agitated, angry 0 1 2 3

3. General feeling of poor health 0 1 2 3

4. Feeling of extreme dryness 0 1 2 3

5. Dry, flaky skin and/or hair 0 1 2 3

6. Bags or circles under eyes 0 1 2 3

7. Deterioration of eyesight, spots 0 1 2 3

8. Yellowish colour or skin or eyes 0 1 2 3

9. Headaches 0 1 2 3

10. Insomnia 0 1 2 3

11. Sinus problems 0 1 2 3

12. Excess mucous formation 0 1 2 3

13. Chronic coughing 0 1 2 3

14. Sore throat, hoarseness, loss of voice 0 1 2 3

15. Swollen or discoloured tongue, gums or lips 0 1 2 3

16. Rapid or pounding heartbeat 0 1 2 3

17. Asthma, bronchitis 0 1 2 3

18. Pain or aches in joints 0 1 2 3

19. Pains or aches in muscles 0 1 2 3

20. Hives, rashes or itchy skin 0 1 2 3

21. Exposure to perfumes, tobacco smoke, exhaust fumes or other chemicals provokes symptoms 0 1 2 3

Total points__________

Section C: STRESS

Do You…..

1. Feel stressed, nervous or tense 0 1 2 3

2. Feel irritable or oversensitive 0 1 2 3

3. Experience difficulty concentrating and thinking clearly 0 1 2 3

4. Have coffee, tea, tobacco, sugar or other stimulants as a pick me up 0 1 2 3

In the past two years, have you experienced…..

5. Divorce N Y (5)

6. Separation from partner N Y (4)

7. Death in the family N Y (4)

8. Breaking the law N Y (4)

9. Bankruptcy N Y (4)

10. Moving house N Y (3)

11. Losing or starting work N Y (3)

Total points__________

Section D: VITALITY

Do You…..

1. Have inadequate energy or fatigue 0 1 2 3

2. Suffer Chronic Fatigue Syndrome 0 1 2 3

3. Find it hard to get up or become motivated in the morning 0 1 2 3

4. Often feel tired or overworked 0 1 2 3

5. Have difficulty staying awake 0 1 2 3

6. Have mid afternoon slump in energy 0 1 2 3

7. Experience mental confusion or sluggishness 0 1 2 3

Total points__________

Section E: WEIGHT MANAGEMENT

Where 0 is very satisfied and 3 is very concerned, rate how you feel about…..

1. The way my body looks 0 1 2 3

2. The way my body feels 0 1 2 3

3. My body fat 0 1 2 3

4. My muscle tone 0 1 2 3

5. My strength 0 1 2 3

6. My endurance 0 1 2 3

7. My flexibility 0 1 2 3

8. My present weight 0 1 2 3

Total points__________

RESULTS

3 or less in a section low priority

3-10 moderate priority

more than 10 high priority

If your score appears too high or you would like to discuss the results of your health questionnaire, contact us at The Medical Sanctuary with your concerns.

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