1

CLIENT INFORMATION

Name ______________________________________________ Ht._______ Wt._______ Age _______ Address ___________________________ City __________________State _______ Zip ___________ D.O.B. _________________________ Home Phone ____________________ Work Phone ___________________ Fax ___________________ mp!oyment _____________________Fami!y Physi"ian ______________ Cardio!ogist. ____________

HEALTH QUESTIONAIRE AND SELF-ASSESSMENT

What is Your Body Telling You?
Thyroid/Parathyroid (Glandular System)
#es #es #es #es #es #es #es #es Strong #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es No No No No No No No No Weak No No No No No No No No No No No No No No No No No Are yo$ o%er&eight' Do yo$ get "o!d hands and (eet' Do yo$ ha%e hair !oss or are yo$ )a!d or going )a!d' *s it easy to p$t on &eight and hard to !oose it' Are yo$r (ingernai!s ridged+ )ritt!e or &eak' Do yo$ ha%e %ari"ose or spider %eins' Do yo$+ or ha%e yo$ had hemorrhoids' Do yo$ get "ramping in yo$r m$s"!es' *s yo$r )!adder strong or &eak' Do yo$ ha%e an irreg$!ar heart)eat' Do yo$ ha%e ,itra! -a!%e Pro!apse (Heart Murmur)? Do yo$ get heada"hes or migraines' Ha%e yo$ no& or ha%e yo$ e%er had a hernia' Ha%e yo$ e%er had an ane$rysm' Do yo$ ha%e osteoporosis' . Do yo$ ha%e s"o!iosis' Do yo$ get irrita)!e easi!y' Do yo$ ha%e !o& energy !e%e!s' Do yo$ s$((er (rom symptoms o( depression' Did yo$ s"ore !o& on yo$r )one density tests' Do yo$r tests "ome )a"k sho&ing .o& Ca!"i$m !e%e!s' Do yo$ ha%e+ or ha%e yo$ e%er had+ a goiter' Do yo$ ha%e spine deterioration or herniated dis"s' Ha%e yo$ )een diagnosed &ith Hashimoto or /eide! disease' (Or any family member?)_________________________________ Do yo$ s&eat pro($se!y or hard!y at a!!'

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

Adrenal Glands (Glandular System)

#es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es No No No No No No No No No No No No No No No No No Medulla (Adrenal) Do yo$ ha%e ,.S.+ Parkinson0s or Pa!sy' Do yo$ ha%e anxiety atta"ks or (ee! o%er!y anxio$s' Do yo$ (ee! ex"essi%e shyness+ or in(erior to others' Do yo$ ha%e !o& )!ood press$re (below 112 systolic)? Do yo$ ha%e tremors+ ner%o$s !egs+ et".' Do yo$ ha%e tinnitis (ringing in the ears)? Do yo$ ha%e S.O.B. (shortness of breath) or is it hard to take a deep )reath' Do yo$ ha%e heart arrhythmias' Do yo$ ha%e a hard time s!eeping' Do yo$ ha%e Chroni" Fatig$e Syndrome' Do yo$ get tired easi!y' Ha%e yo$ e%er )een diagnosed &ith Addison0s Disease or &ith Congenita! Adrena! Hyperp!asia' Cortex (Adrenal) Do yo$ ha%e e!e%ated )!ood "ho!estero! !e%e!s' Do yo$ ha%e !o&er )a"k &eakness' Do yo$ ha%e+ or ha%e yo$ had+ s"iati"a' Do yo$ ha%e arthritis or )$rsitis' Do yo$ ha%e any 3itis0s (inflammatory conditions)? Explain:

Female Only
#es #es #es #es #es #es #es #es #es #es #es #es #es #es No No No No No No No No No No No No No No Are yo$r menstr$ations irreg$!ar' Do yo$ get ex"essi%e )!eeding d$ring menstr$ation' Do yo$ ha%e or ha%e yo$ had o%arian "ysts' Do yo$ ha%e or did yo$ ha%e (i)roids' Do yo$ ha%e or did yo$ ha%e endometriosis or A4typi"a! "e!!s' Are yo$ (i)ro"ysti"' Do yo$ ha%e (i)romya!gia or s"!eroderma' Do yo$ get sore )reasts+ espe"ia!!y d$ring menstr$ation' Do yo$ ha%e a !o& or ex"essi%e sex dri%e' Ha%e yo$ had a hystere"tomy' When' ________________________ artial_____ !omplete ______ Anything ($rther to add5 _________________________________________ Did they take any other organs o$t at the same time' 6 c" a" #allbladder) Ha%e yo$ had a D 7 C' Ha%e yo$ had a mis"arriage' Ha%e yo$ had di((i"$!ty in "on"ei%ing "hi!dren' Other

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

Male Only
#es #es #es #es #es #es No No No No No No Do yo$ ha%e prostatitis (fre$uent urination esp" at night)? %f yes& how often?_________________________ Do yo$ ha%e prostate "an"er' PSA "o$nt0s5_______________________ Do yo$ ha%e testi"$!ar hypertrophy (enlargement)? Do yo$ ha%e a !o& or ex"essi%e sex dri%e' Do yo$ ha%e ere"tion pro)!ems' Do yo$ ha%e premat$re e8a"$!ation' Other

Pan reas
#es #es #es #es #es #es #es #es #es #es No No No No No No No No No No Do yo$ get gas a(ter yo$ eat' Do yo$ (ee! yo$r (oods 8$st sitting in yo$r stoma"h' Do yo$ ha%e A"id /e(!$x' Do yo$ see any $ndigested (oods in yo$r stoo!s' Do yo$ ha%e hypog!y"emia ('ow (lood )ugar)? Do yo$ ha%e Dia)etes (High (lood )ugar)? 9ype * ____ or 9ype ** _____ Are yo$ thin and ha%e a hard time p$tting on &eight' Do yo$ ha%e gastritis or enteritis' Do yo$r (oods pass right thro$gh yo$ (diarrhea)? Do yo$ ha%e mo!es on yo$r )ody'

Gastro!"ntestinal Tra t
#es #es #es #es #es #es #es #es
Dai!y ; ____

#es #es #es #es #es #es #es

*s yo$r tong$e "oated (white& yellow& green or brown)& espe"ia!!y in the morning' No Do yo$ ha%e a Hiat$s Hernia' No Do yo$ ha%e :astritis' No Do yo$ ha%e nteritis' No Do yo$ ha%e Co!itis' No Do yo$ ha%e Di%erti"$!itis' No Do yo$ get or ha%e Diarrhea' No Do yo$ get or ha%e Constipation' Week ; ____ Ho& o(ten do yo$ ha%e a Bo&e! ,o%ement' No Ha%e yo$ e%er had stoma"h or intestina! $!"ers' When' _______________ No Do yo$ or ha%e yo$ e%er had any type o( gastro4intestina! "an"ers5 stoma"h+ "o!on+ re"ta!+ et". xp!ain5 No Do yo$ ha%e Crohn0s Disease' No Do yo$ ha%e 3gas3 pro)!ems' No Other :* pro)!ems5

No

#i$er/Gall%ladder/Blood
No No Do yo$ ha%e a pro)!em digesting (ats' Do (ats or dairy (oods "a$se )!oating and<or pain in the stoma"h area'

#i$er/Gall%ladder/Blood ( ontinued&)

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

#es #es #es #es #es #es #es #es

No No No No No No No No

Are yo$r stoo!s &hite or %ery !ight )ro&n in "o!or' Do yo$ get pain in the midd!e o( yo$r )a"k (especially after eating)?

Do yo$ get pain )ehind the right+ !o&er ri) area'

Do yo$ ha%e 3!i%er3 or )ro&n spots on yo$r skin' (not frec*les) Do yo$ ha%e any skin pigmentation "hanges' Do yo$ ha%e skin pro)!ems' *( so+ &hat type' _______________________ Are yo$ anemi"'

Do yo$ ha%e+ or ha%e yo$ e%er had+ hepatitis' A____+ B____+ C_____

'eart ( )ir ulation

#es #es #es #es #es #es #es #es #es #es #es #es No No No No No No No No No No No No Do yo$ ha%e any gray hair' Do yo$ ha%e a hard time remem)ering things' Do yo$r !egs get tired or "ramp a(ter yo$ &a!k' Do yo$ )r$ise easi!y' Do yo$ get "hest pains or angina' Ha%e yo$ e%er had a heart atta"k (Myocardial %nfarction)? Ha%e yo$ e%er had open4heart s$rgery' Do yo$ ha%e heart arrhythmia0s' What kind' ___________________________________________________ Do yo$ ha%e a heart m$rm$r or ,itra! -a!%e Pro!apse' Do yo$ e%er (ee! press$re on yo$r "hest' Do yo$ get 3pri"k!y3 pains any&here+ espe"ia!!y in the heart area' Where' ______________________________________________________ Do yo$ ha%e+ or ha%e yo$ e%er had High B!ood Press$re' #o$r a%erage B!ood Press$re is _________o%er ________

S*in
#es #es #es #es #es #es #es #es #es #es #es #es #es #es No No No No No No No No No No No No No No Do yo$ get or ha%e skin rashes' Do yo$ get skin )!emishes' Do yo$ ha%e "=ema or Dermatitis' Do yo$ ha%e Psoriasis' Do yo$ it"h any&here' Where' __________________________________ *s yo$r skin dry' *s yo$r skin ex"essi%e!y oi!y' Do yo$ get or ha%e dandr$(('

#ym+hati System
Are yo$ a!!ergi" to anything' What' _______________________________ Do yo$ e%er get "o!ds or (!$4!ike symptoms' Do yo$ ha%e sin$s pro)!ems' Do yo$ ha%e or get sore throats' Do yo$ ha%e s&o!!en !ymph nodes' Do yo$ ha%e or had t$mors' What type' +atty ___ (enign____ !ancerous ___ ,here? _______________________________________________________

#ym+hati System ( ontinued&)

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

#es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es #es

No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No

Do yo$ ha%e a !o& p!ate!et "o$nt 6)!ood>' *s yo$r imm$ne system !o& or s!$ggish' Ha%e yo$ had appendi"itis or an appende"tomy' When' _______________ Do yo$ get )oi!s+ pimp!es+ and the !ike' Do yo$ ha%e a!!ergies' Ha%e yo$ e%er had a)s"esses' Ha%e yo$ e%er had toxemia' Do yo$ ha%e+ or ha%e yo$ had+ "e!!$!itis' Ha%e yo$ e%er had go$t' Do yo$ get )!$rred %ision' Do yo$ ha%e m$"$s in yo$r eyes &hen yo$ &ake $p in the morning' Do yo$ snore' Do yo$ ha%e s!eep apnea' Ha%e yo$ had yo$r tonsi!s o$t' What age' ____________

,idneys & Bladder

Ha%e yo$ e%er had a $rinary tra"t in(e"tion (-.%/s)? Ha%e yo$ e%er had 3)$rning3 $pon $rination' Do yo$ ha%e pro)!ems ho!ding yo$r )!adder (para0thyroid)? Ha%e yo$ e%er had kidney stones' Do yo$ ha%e )ags $nder yo$r eyes (esp" in the morning)? *s yo$r $rine (!o& restri"ted' Do yo$ get "ramping or pain on either side o( yo$r mid4to4!o&er )a"k' Do yo$ or did yo$ e%er ha%e nephritis' Do yo$ or did yo$ e%er ha%e "ystitis'

#ungs
Do yo$ get or ha%e 6or ha%e had> )ron"hitis' Do yo$ get or ha%e 6or ha%e had> emphysema' Do yo$ get or ha%e 6or ha%e had> asthma' Do yo$ get or ha%e 6or ha%e had> C.O.P.D.' Are yo$ on inha!ers or ne)$!i=ers' Ho& o(ten' _______________________ What type' ___________________________________________________ Do yo$ kno& &hat yo$r oxygen sat$ration is' Do yo$ get pain &hen yo$ )reathe' Do yo$ get pain &hen yo$ take a deep )reath' Did yo$ e%er or do yo$ ha%e !$ng "an"er' Do yo$ ha%e a "o!!apsed !$ng' Are yo$ a smoker' Ho& o(ten' ? per day ___________________________ Ha%e yo$ e%er had pne$monia' Ha%e yo$ e%er &orked aro$nd toxi" "hemi"a!s+ in "oa!mines or aro$nd as)estos' Do yo$ "o$gh a !ot' Do yo$ get any m$"$s &hen yo$ "o$gh' ,hat color is the mucus? ________________________________________

Other (What are your main health om+laints or on erns?)

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

P!ease !ist and e!a)orate on any "onditions or symptoms that this @$estionnaire has not "o%ered or asked yo$.

Past Surgeries
P!ease !ist any past s$rgeries yo$ ha%e had (e"g" tonsils remo1ed& hysterectomies& open heart surgery" etc")

Surgery

Year

)hemi al Medi ations

P!ease !ist any "hemi"a! medi"ations that yo$ are present!y taking5

Medi ation

-eason.

/atural Su++lements
P!ease !ist any nat$ra! s$pp!ements yo$ are "$rrent!y taking5

Su++lements. 0itamins1 Minerals1

'er%s and/or Botani als

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om

Allergies
P!ease !ist anything that yo$ are a!!ergi" to5

Allergy

A++ro2 date/year you 3irst noti ed the allergy

Geneti 'istory
,om5 Dad5 ,aterna! :rand(ather5 6,aterna!> :randmother5 6Fraterna!> :rand(ather5 6Fraterna!> :randmother5 Sister5 Sister5 Brother5 Brother5

Anything 3urther to add (notes1 omments1 et 4).

Thank Yo !

2014 Zunzun Caribbean Wellness Center and Health Retreats, St. Thomas, US ! 00"02 ###.HealthWellnessRetreat$%mail.&om ' ()40* ++,-,02. ' HealthWellnessRetreat$%mail.&om