If you have already completed the Health Review Questionnaire
but not paid your membership fee as yet, please enter your email address below and click the continue button. Or, 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 :
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Firstly, I welcome you as a valued MassAttack patient. To ensure your credit card details are secure, I guarantee that all payments are housed through Westpac's secure banking facility. We do not store credit card details on our site. Once completed, this questionnaire will be forwarded straight to the MassAttack clinic's naturopathic team for review.

Following payment of $149, an evaluation process will be undertaken and your program developed. This process may take around 7 days.

It won't take you long
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.

You can't fail!

Remember, if you feel that you have missed something, you can call to chat on 1300 133 536 or email me at info@massattack.com.au

If you feel that once you receive your program I have missed something, please let me know and I will re do your program at no extra cost.

Go for it, you will do great!


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: 
 
*  What is your main health concern? 
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Section 2
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Sub Section 2a
What is your occupation?
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      
If yes, how many kilos would you like to lose?
1-5 kgs      6-12 kgs      13-19 kgs      20-30 kgs      30+ kgs     
Do you feel that you are underweight?
Yes       No      
If yes, by how many kilos?
1-2 kgs      3-5 kgs      6+ 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      
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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      
If yes, are you taking any medications for continued treatment? Yes       No      
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
A recent trauma in the past two years? 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
An irritable or hyperactive bowel 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 Lumpy breasts
Intolerance to cold Dry skin Heavy periods
Continuous, stubborn weight gain
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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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Sub Section 5c
Have you taken antibiotics regularly? Yes       No      
How long have you been suffering from a lowered immune system?
1 mth         3 mths       6 mths       12 mths       2 yrs       6 yrs       More    
Do you experience? (Tick where applicable)
Unexplained weight loss of 4-5kg in the last three months Hair is easily plucked out, or falls out, grows slowly Infections - eyes, ears, nose, throat, lungs, skin
Dark areas on cheeks, under eyes Puffy face Dark circles under the eyes
Eyes tear, burn, discharge Diarrhoea Cold sores, bleeding
Difficulty seeing at night Ears continuously drain Wounds heal slowly
Cough with mucus Inflamed or bleeding gums Gums swelling, bleeding
Catch colds easily Lack of appetite Bumpy skin on back of arms
Nasal congestion or discharge - thick, yellow, green Sore throat or post-nasal drip Lips are red, swollen, raw looking
Impaired taste and smell Neck, armpit, groin swelling Nail discolourations
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Sub Section 5d
Do you experience? (tick where applicable)
Muscles fatigue quickly Moody, irritable, tired
Severe joint pain, redness, swelling Severe fatigue
Migraine headaches Chronic pain, stiffness throughout body
Sensitive to light (skin or eyes) Specific food(s) worsen pain, inflamation, stiffness
Nails loosen, pitted, discoloured Clear, watery discharge from nose, eyes
Swollen-looking face or body Localised or general itching - eyes, ears, throat, nose, skin
Sneezing Extreme dryness of eyes, nasal passages, mouth
Cough or wheezing Mouldy, damp environments trigger sickness
Post nasal drip with certain foods Heart palpitations after eating certain foods
Weight loss, muscle weakness Scalp hair falls out easily, in clumps
Hair loss, entire body Bruise easily
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Sub Section 5e
Do you suffer from...? (please tick those applicable)
Acne Psoriasis
Eczema Dermatitis
Warts Tinea
Dandruff Rashes
Are you satisfied with the condition of your skin? Yes       No      
Further information:
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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 premenstrually? (please 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 perimenopausal? (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, nausea
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 pattern 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 during pregnancy
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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Sub Section 7a
Please tick those below you experience
Tinea Difficult or irregular bowel movements Intolerance to fatty foods
High cholesterol Abdominal bloating Allergies
Sores in the corners of your mouth Offensive body odour Skin rashes
Vaginal Candida Digestive problems Vaginal infections or itching
Indigestion, heartburn or reflux following a meal
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Sub Section 7b
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:
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Sub Section 7c
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:
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Sub Section 7d
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:
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Sub Section 7e
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:
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Sub Section 7f
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:
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Sub Section 7g
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:
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Section 8
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Please tick those below you experience?
Generalised bone tenderness, achiness Localised bone pain Bone deformity or swelling
Joint pain and stiffness especially spine, hips, kness Crunching or creaking sounds when moving joints Hands, feet, throat spasm or feel numb
Tooth cavities Established bone loss Unexplained bone fracture
Calcium deposits Recent loss of height Walking difficulties, limp
Irregular patches of increased pigmentation
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Section 9
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Do you have impulsive tendencies?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from feelings of being down or depressed?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have panic attacks or anxiety?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel more depressed or down during winder months?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel angry or aggressive?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have several suicidal thoughts?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel nervous when you have to go to public places?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you avoid situations where there will be a large amount of people?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from headaches?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have problems with self esteem?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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Do you dwell for an extended period of time over a major personal life event eg relationship breakup, financial worries?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you find yourself repeating certain actions constantly eg hand washing, checking that the door is locked?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Are you more sensitive to pain than others (low pain tolerance)?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel aggressive when drinking alcohol?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel constantly worry about your body size?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you crave/actively seek behaviour such us gambling, extreme sports, recreational drug use, frequent excess alcohol use?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel tense, anxious and worried a lot?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have a negative reaction to or dwell over stressful situations?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you partake in physical activity less than twice per week?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do your legs jump when you are asleep?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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Do you have short attention span and find it difficult to concentrate?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Have you suffered chronic stress in the past coupled with fatigue?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Have you previously used large amounts of stimulants?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you put on weight easily and find it difficult to lose weight?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from stress urinary incontinence?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from chronic pain?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you find it difficult to remember what happened a long time ago?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from frequent cluster headaches or migraines?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from hypoglycaemia?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you often have a relatively high tolerance to pain?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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Do you have feeling of anxiety?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you seem to need more sleep than others?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have difficulty waking in the morning?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel constantly fatigued?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you find it difficult to concentrate?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have hyperactive tendencies?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you suffer from halucinations (or see things that are not there)?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you find that cuts and sores take a while to heal?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel nervous or worry about doing something you haven't done before?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you crave alcohol?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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Have you been diagnosed with epilepsy or suffer seizures?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you experience manic episodes or feelings of mania?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you misplace objects frequently?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have trouble remembering the details of what happened yesterday?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have low sex drive?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel there is significantly high stress in your life?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you have difficulty learning something new?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you feel unmotivated and can't get into what each day has to offer?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Are you dreams vague and plain?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do your muscles constantly feel tight?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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Do you have difficulty rapidly processing new information?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Have you been diagnosed with dementia or Alzheimer's disease? Yes       No      
Do you have poor coordination or balance?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Are you a light sleeper and wake frequently during the night?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Have you developed more digestive symptoms/discomfort as you have aged?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
Do you find it difficult to make decisions?
Never      1-2 times/month      3-5 times/month      6-15 times/month      +15 times/month     
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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 or email to testresults@massattack.com.au
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Submit your Questionnaire
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To proceed with payment click the submit button.
 
   
   
   
   
     
 
 

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