If you have already completed the DETOX Health Review Questionnaire but not paid your membership fee as yet, please enter your email address below and click the continue button. If it has been longer than six weeks since you completed you questionnaire you may find that it has expired. If your email address is not recognised please complete the questionnaire again. Email Address :

If this is your first visit to my Questionnaire, well done for taking the first step on the journey to a healthier and happier you. I welcome you as a valued MassAttack patient. For me to help you I need you now to complete a comprehensive Health Review Questionnaire. Once completed, this questionnaire will be forwarded straight to the MassAttack clinic's naturopathic team.

Following payment of $495, an evaluation process will be undertaken and your program developed. This process may take around 7-14 days.

•It won’t take you long
Now get comfortable and then work through the following questionnaire, remembering to answer each applicable question as honestly as you can. You’ll find my questionnaire quite extensive but, this being said, it shouldn’t take you any longer than 20 minutes to complete.

•How to answer the ‘curly’ questions
If you find it difficult to give a definitive yes or no answer, please only tick ‘YES’ if it is a symptom you have experienced regularly over the last three months. I want to get an understanding of what the norm is for you. Remember, if you need to elaborate or clarify a response you can do so at the end of the questionnaire.

•Answer every question
Make sure you answer every applicable question, including questions repeated in different sections. The more truthful your answers, the better we can tailor the program specifically to address your hormonal needs. This is not the time to be shy!

Go for it, you will do great!

Winner ANPA "Australian Naturopathic Excellence Award 2006"

Winner ANPA "Community Education Excellence Award 2009"

Section 1 Personal Information

You may be asked to repeat some questions in different sections of the questionaire. Please answer each question again where prompted so we may accurately track your Health Review responses. Please note: Fields marked with a * must be completed   *  First Name   *  Surname         *  Email     *  Daytime Phone   * please include your area code      Mobile Phone     *  Country Please select country... Afghanistan Albania Algeria Albania American Samoa Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia & Herzegovina Botswana Brazil British Indian Ocean Ter Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Ter Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Hawaii Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Malawi Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Midway Islands Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherland Antilles Netherlands (Holland, Europe) Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Island Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Republic of Montenegro Republic of Serbia Reunion Romania Russia Rwanda St Barthelemy St Eustatius St Helena St Kitts-Nevis St Lucia St Maarten St Pierre & Miquelon St Vincent & Grenadines Saipan Samoa Samoa American San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Is Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (Brit) Virgin Islands (USA) Wake Island Wallis & Futana Is Yemen Zaire Zambia Zimbabwe       *  Age Please select age range 10 to 14 15 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 64 64 or over       *  Your height   centimeters     (or)      inches (5' = 60")   *  Your weight   kilograms         (or)      pounds (14lbs = 1 stone)   *  To assist with our marketing, please choose the source that led you to find our website:  Please select An Online Forum Australian Unity Brisbane's Child Bub Hub Canberra Child Contours Google Grazia magazine Insight magazine Internet Search Engine Living Now Mass Attack Member (please list name) Melbourne's Child Members Benefit Program My Health Specials New Idea Nova Options magazine Other Print (please advise) Other Source (please specify) Other Website (please advise) Past Member Personal Trainer(please list name) Perth Child Sydney's Child Take 5 That's Life Woman's Day Yahoo Yellow Pages Your Health Advisor/Doctor(please list name)

Section 2

Sub Section 2a What is your occupation? Please note: Are you currently taking or using any prescriptive medications?   * Yes       No        If yes, please list here: Are you taking any over the counter medications?   * Yes       No       If yes, list them here Are you taking any natural remedies?   * Yes       No       If yes, please list them here Sub Section 2b How many cups of caffeinated beverages (coffee, soda, tea) do you drink per day? 0       1       2-3       4 or more       Do you drink alcohol? Yes       No       If yes, how many standard alcoholic drinks per week? 1-3       4-6       7-10       11 or more       Do you smoke? Yes       No       If yes, how many packs of cigarettes a week? less than 1       1       2-3       4 or more       Do you feel that you are overweight? Yes       No       Underweight       If yes, how many kilos would you like to lose? 1-5 kgs      6-12 kgs      13-19 kgs      20-30 kgs      30+ kgs      Have any members of your immediate family suffered from weight gain? Yes       No       Have you ever had a drug addiction? Yes       No       Have you used any recreational drugs in the past 12 months? Yes       No       Sub Section 2c Have you had any recent surgery?   * Yes       No       If yes, how long ago was the surgery? 1-3 months       5-12 months       1 year plus       If yes, please indicate the type of surgery Full hysterectomy Partial hysterectomy Gall bladder removal Ovarian Cyst or fibroid removal Tumour removal Thyroid removal Other Surgery (please list) Have you ever suffered from cancer? Yes       No       If yes please indicate what type of cancer? Breast Cancer Cervical Cancer Lymphatic Endometrial Brain Bowel Thyroid Other Cancer (please list) If yes, please indicate cancer treatment received Surgical Removal Radiotherapy Chemotherapy Other Cancer Treatment (please list) *Note: If you taking any medications for continued cancer treatment, please list in section 2a above. If yes, how long ago was the cancer diagnosis? 0-6 months       7-12 months       1 year plus       If yes, how long ago was your last cancer treatment? 0-6 months       7-12 months       1 year plus       Do you suffer from Type 1 Diabetes? Yes       No       Do you have Type 2 Diabetes? Yes       No       If yes, are you taking any medications for Diabetes? (If yes please list in Section 2a) Yes       No

Section 3

Sub Section 3a Do you suffer from digestive disturbances? (tick applicable boxes) Excessive belching, burping and/or bloating Sense of fullness during and after meals History of anaemia, unresponsive to iron Indigestion Poor appetite, disinterest in food Offensive breath Gas immediately following a meal Partial loss of taste or smell Difficulty swallowing Difficult bowel movement Unintentional weight loss Sores in corner of mouth Vegetarian (no eggs, dairy) Picky eater Spoon shaped nails Bad taste in mouth Smooth tongue Further information: Sub Section 3b Do you suffer from...? (tick applicable box) Indigestion and fullness lasts 2-4 hours after eating Specific foods/beverages aggravate indigestion Pain, tenderness, on left side under ribcage Excessive gas Abdominal cramps, aches Nausea and/or vomiting Dry, flaky skin or dry, brittle hair Difficulty gaining weight Weakness and fatigue Three or more large bowel movements a day Roughage and fibre cause constipation Bloated Alternating constipation and diarrhoea Stool poorly formed Stool - undigested food Stool - greasy, shiny Stool - yellowish, foul smelling Mucus in stool Black stool Rectal spasms Dark urine Bone and back pain Pounding heart Iron deficiency anaemia Further information: Sub Section 3c Do you suffer from...? (tick applicable boxes) Feeling hungry an hour or two after eating Stomach pain, burning, aching, 1-4 hours after eating Difficulty or pain when swallowing Strong emotions, thought or smell of food aggravates stomach Chest pain, difficulty breathing, lung infections Heartburn due to spicy and fatty foods, chocolate, chilli peppers, citrus, alcohol, caffeine Constipation, difficult bowel movements Heartburn, especially when lying down or bending forward Black, tarry stool Digestive problems subside with rest and relazation Unexplained weight gain Antacids, carbonated beverages, cream/milk food relieves symptoms Further information: Sub Section 3d Do you suffer from...? (tick applicable boxes) Excessive gas and bloating Lower abdominal pain, relief by passing stool or gas Diarrhoea (loose watery stool) Raw fruits, vegetables and stress aggravate bowel pain More than three bowel movement daily Lower abdominal pain, cramping and/or spasms Hard, dry or small stool Painful, difficult, straining during bowel movements Extremely narrow stools Alternating diarrhoea/constipation Mucus and pus in stool Feel bowels do not empty completely Rectal pain or cramps Bright red blood following bowel movement Anal itching Rash under breast, armpit, around naval or groin area Irritable, moody Feel ill in damp, mouldy settings or rainy weather Further information: Sub Section 3e Do you suffer from...? (tick applicable boxes) Moderate to severe pain under right side of ribcage Stool colour alternates from clay colour to normal brown Abdominal pain worse with deep breathing Unexplained itchy skin, worse at night Unable to concentrate, irritable, confused Weight gain due to water retention Belching, heartburn, gas Feel restless, agitated, angry Bloated, full feeling Yellowish colour to skin, eyes Loss of skin elasticity General feeling of poor health Fatigue, weakness, exhaustion Bitter fluid repeats after eating Aching muscles Reddened skin, especially palms Fatty foods cause indigestion Swollen feet and/or legs Bleeding tendencies in gums, nose Loss of chest and armpit hair Trembling hands Dark urine, diminished flow Dry, flaky skin and/or hair Loss of appetite and weight Easily bruised Thinning of public hair Feeling of extreme dryness Further information: Sub Section 3f Do you suffer from...? (please tick below where applicable) Retain fluid throughout body Excessive urination Burning with urinating Bloody, cloudy and/or darken urine Difficulty passing urine Strong smelling urine Further information:

Section 4

Sub Section 4a Are you pregnant?   * Yes       No       If yes, how many months are you? 1-3 months       4-6 months       6 plus months       Are you breastfeeding?   * Yes       No       About to finish       If you have children, how old is your youngest? 0-3 months       4-6 months       7-12 months       1 year plus       Do you wish to have a child in the next 12 months? Yes       No       Sub Section 4b Do you experience? (tick where applicable) Salt cravings Rapid mood swings Feel irritable or over sensitive Foggy thinking or poor concentration Feel exhausted or daunted Feel like crying for no reason An irritable or hyperactive bowel Need coffee, tea, sugar, tobacco or other stimulants to get through the day Work shift work or long hours Difficulty sleeping Fatigue, especially in the mornings Lowered immune system (always getting sick) Rapid heart beat Dizziness and or fainting Low blood pressure Excessive perspiration Excessive perspiration Long term use of anti inflammatory drugs or cortisone A trauma two or more years ago? Extreme physical exercise Drug or alcohol abuse Anxiety attacks Does life sometimes overwhelm you? Yes       No       Do you worry excessively? Yes       No       Are you a perfectionist? Yes       No       Do you consider yourself highly strung? Yes       No       Sub Section 4c Do you suffer from Hypertension (high blood pressure)?   * Yes       No       Don't Know       Do you suffer from Hypotension (low blood pressure)?   * Yes       No       Don't Know       Do you have high Cholesterol?   * Yes       No       Don't Know       Do you suffer from Ulcers eg gastric/duodenal? Yes       No       Don't Know       Do you suffer from Anaemia? Yes       No       Don't Know       Do you suffer from Hashimoto’s Disease? Yes       No       Don't Know       Do you suffer from Grave’s Disease? Yes       No       Don't Know       Do you suffer from Hypothyroidism (under active thyroid)? Yes       No       Don't Know       Do you suffer from Hyperthyroidism (over active thyroid) ? Yes       No       Don't Know       Sub Section 4d Are you being affected by? (please tick where applicable) Continuous fatigue Cold hands and feet Times of depression Muscles cramp and tremble Weight gain generally Lumpy breasts Intolerance to cold Dry skin Heavy periods Continuous, stubborn weight gain Sub Section 4e Do you suffer from Fibromyalgia Yes       No       Don't Know       Have you had Glandular Fever or Epstein Barr Virus? Yes       No       Don't Know       Do you suffer from auto immune disturbances? Yes       No       Don't Know       Are you experiencing? (tick below if yes) Aching muscles Joint pain Debilitating fatigue Tightness in your throat Sub Section 4f Do you have any other chronic illness or medical condition?   * Yes       No       If yes please list these here Sub Section 4g Have you ever given birth? Yes       No       If yes, was it a lengthy complicated birth? Yes       No       If yes, did you haemorrhage (lose a lot of blood) during labour? Yes       No       Do you currently use an Intrauterine Device (IUD)? (If yes, please list in section 2a) Yes       No       Do you currently take an oral contraceptive pill? (If yes, please list in section 2a) Yes       No       Do you currently use other prescriptive contraceptives e.g implant, injection? (If yes, please list in section 2a) Yes       No       Did you get your first period before age 10? Yes       No

Additional information or clarification

Is there something you were unable to express and would like me to call you to chat about? Yes       No       Please write briefy and to the point If you have any recent blood tests please fax them to (03) 9852 9933

Submit your Questionnaire

Please submit your questionnaire to the MassAttack clinic's naturopathic team.