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Email Address :

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Section 1 Personal Information
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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    
 
*  Age    
 

*  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: 
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Section 2
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Sub Section 2a
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
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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      
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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
Thyroid removal Tumour removal Ovarian Cyst or fibroid 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      
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Section 3
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Sub Section 3a
Generally, do you feel? (tick applicable boxes)
Challenged Unmotivated Depressed
Fearful of food You have a low libido Depleted
Alienated Discouraged Anxious
Out of control Overwhelmed Unattractive
Apathetic Fearful Angry
Do you feel you need to? (tick if applicable)
Forgive and forget Move forward Make changes in your life
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Sub Section 3b
Did you gain weight after? (please tick where applicable)
Pregnancy During Menopause Retirement
Divorce Giving up sport Giving up smoking
Major life trauma
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Sub Section 3c
Do you participate in the following behaviours in an attempt to lose weight? (please tick below where applicable)
Exercise excessively Vomit Use chemical laxatives
Avoid eating Use natural laxatives e.g. bran, prunes, herbs  
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Section 4
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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      
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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
A recent trauma in the past two years? 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      
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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      
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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 Continuous, stubborn weight gain
Intolerance to cold Dry skin Heavy periods
Lumpy breasts
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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
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Sub Section 4f
Do you have any other chronic illness or medical condition?   * Yes       No      
If yes please list these here
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      
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Section 5
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Sub Section 5a
Were you overweight as a child? Yes       No      
At what age did you begin struggling with your weight?
5-10yrs         11-15yrs       16-22yrs       23-30yrs       31-40yrs       41-50yrs       51yrs plus     Never      
Where are your weight problem areas? (Tick below where applicable)
Arms Breasts Neck
Waist Hips Bottom
Thighs Calves All Over
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Sub Section 5b
Do You? (please tick those applicable)
Become tired mid afternoon Have a tendency to accumulate fat around the waist
Become hungry mid afternoon Snack at night
Snack on sweets and sugary foods Crave carbohydrates e.g. pasta, rice, bread, fruit
Eat high fat foods Eat bread, pasta and rice
Eat when you are not hungry Feel drowsy after eating
Awake from sleep around 3am Lack concentration
Experience excessive hunger
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Section 6
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Sub Section 6a
Do you have a menstrual bleed (period)? Yes       No      
If so, how long is your average menstrual cycle?
20 days or less       21-27 days       28-32 days       33 days plus
Have you been experiencing?
An irregular menstrual cycle. For example, cycle lengths that vary greatly? Yes       No      
Are your periods generally more than 45 to 50 days apart? Yes       No      
Are your periods generally less than 20 days apart? Yes       No      
Are your periods generally exceptionally light? Yes       No      
Are your periods generally very heavy? Yes       No      
Are your periods so heavy that they interfere with your lifestyle or regular activities? Yes       No      
Please indicate the average duration of your menstrual bleed?
1-3 days       4-6 days       7 days plus      
Do you spot between periods or have any unexplained bleeding? Yes       No      
Are you passing large clots? Yes       No      
Do you feel weak or dizzy during your period? Yes       No      
During menstruation, do you have mild to moderate pelvic pain or cramping? Yes       No      
During menstruation, do you have severe or debilitating pelvic pain or cramping? Yes       No      
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Sub Section 6b
Do you suffer from Premenstrual Syndrome? Yes       No      
Do you experience the following symptoms Pre Menstrually? (pls tick those applicable)
Tender or swollen breasts Bloating or fluid retention Headaches or Migraines
Pain or Cramping Fatigue Mood swings
Depression Anxiety Poor sleep patterns
Sugar cravings Increased appetite
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Sub Section 6c
If you have ceased menstruation (post menopause) please skip this section and go to section 6d
Do you ovulate? Yes       No       Don't Know      
How often do you ovulate?
Monthly       Irregularly       Don't Know      
How long is the duration of your ovulation?
1-2 days       3 days plus       Don't Know      
Do you experience pain on ovulation? Yes       No       Don't Know      
Do you experience mucus secretions upon ovulation? Yes       No       Don't Know      
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Sub Section 6d
Are you peri menopausal? (Starting menopause) Yes       No       Don't Know      
Are you mid menopause? Yes       No      
Are you post menopausal? (periods have ceased) Yes       No      
Do you suffer or have noticed the following symptoms? (if so pls tick those applicable)
Hot flushes Sweating Insomnia (can't sleep)
Joint pain Headache Palpitation
Nervous irritability Periods of Depression Lack of concentration
Vaginal dryness Low Libido Weight gain
Changes in menstrual cycle
Are you taking any prescriptive medication for menopause? (If so, please list in section 2a) Yes       No      
Are you taking any natural or over the counter remedies for menopause? (If so, please list in section 2a) Yes       No      
Are you using bio identical hormones to treat menopause? (If so, please list in section 2a) Yes       No      
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Sub Section 6e
Have you been diagnosed with Endometriosis?   * Yes       No      
Do you experience? (tick those applicable)
Pelvic pain Pain before and or after menstruation
Severe menstrual cramps Painful intercourse or orgasms
Bladder pain and or frequency of urination Heavy or irregular menstrual bleeding
Fatigue Intestinal distress such as bloating, vomiting, nause
Lower back pain Painful bowel movements often with cycles of diarrhoea and constipation
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Sub Section 6f
Have you been diagnosed with Polycystic Ovarian Syndrome? (PCOS)   * Yes       No      
Do you experience? (Tick those applicable below)
Irregular or absent periods Acne Excessive or unwanted hair growth
Male patterned balding Excessive weight gain
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Sub Section 6g
Have you been diagnosed with Ovarian Cysts?   * Yes       No      
Tick those symptoms you are experiencing?
Pelvic pain just before your period begins or just after it ends Pelvic pain. A dull ache, either constant or intermittent, possibly radiating to the low back or thighs
A fullness or heaviness in your abdomen Feeling of pressure on your bladder or rectum
Pelvic pain during intercourse Nausea or breast tenderness similar to if you were pregnant
Continuous, creamy or clear like (eggwhite) vaginal discharge that persists unchanged for a month or more
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Sub Section 6h
Have you been diagnosed with Fibroids?   * Yes       No      
Tick those symptoms you are experiencing?
Heavy periods Anaemia
Difficulty conceiving Need to pass urine more often than normal
Constipation Pain or discomfort during sexual intercourse (Dyspareunia)
Severe pain Discomfort in your lower abdomen (tummy)
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Section 7
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Please tick those below you experience?
Do you suffer from Tinea? Difficult or irregular bowel movements Intolerance to fatty foods
High cholesterol Abdominal bloating Allergies
Sores in the corners of your mouth Have offensive body odour Skin rashes
Vaginal Candida Digestive problems Vaginal infections or itching
Indigestion, heartburn or reflux following a meal
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Additional information or clarification
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Please write briefy and to the point
If you have any recent blood tests please fax them to (03) 9852 9933
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Submit your Questionnaire
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Please submit your questionnaire to the MassAttack clinic's naturopathic team.
 
   
   
   
   
     
 
 

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