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 :

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 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

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 Empower Facebook Google Grazia magazine Inflight magazine Insight magazine Internet Search Engine Living Now Mass Attack Member (please list name) Maternal and Child Health Centre 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 YouTube Your Health Advisor/Doctor(please list name)   *  What is your main health concern?  Please select weight fatigue thyroid depression immunity reproductive health insomnia menopause PCOS stress detox candida diabetes fertility

Section 2

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 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       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

Section 3

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 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 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

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 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       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 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

Section 5

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 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 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 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 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:

Section 6

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       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 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       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       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 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 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 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)

Section 7

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 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: 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: 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: 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: 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: 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:

Section 8

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

Section 9

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      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      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      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      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      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

Additional information or clarification

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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