Vitamins Questionnaire
GENERAL ASSESSMENT
Last name
*
First name
*
Gender
*
Please Select
Female
Male
Non-binary
Other
Age
*
E-mail
*
City
*
How did you hear about survey?
*
1.) In the last 12 months, how often have you taken antibiotics?
5 or more times
3-4 times
1-2 times
None
2.) How many servings of fruits do you eat daily?
5 or more servings
2-4 servings
0-1 servings
3.) How many servings of vegetables do you eat daily?
0-1 servings
2-4 servings
5 or more servings
4.) On average, how many servings of calcium-rich food (dark greens, yogurt, tofu, sesame seeds, milk, fortified foods, cheese etc) do you have each day?
3 or more servings
2 servings
1 serving
None
5.) Are you a vegetarian?
Yes
No
6.) How much coffee do you consume on a daily basis?
More than 3 cups
1-2 cups
None
7.) Do you consistently experience loose bowels more than 3 times a week?
Yes
No
8.) How often do you have a bowel movement per week?
After every major meal
7-10 or more
5-7
3-4
Less than 2
9.) Do you experience seasonal or chronic allergies?
Yes
No
10.) Do you suffer from Crohn's, ulcerative colitis, or IBS?
Yes
No
If yes, please specify:
11.) Have you been medically diagnosed with gall stones?
Yes
No
12.) Have you had your gallbladder removed?
Yes
No
13.) Have you been medically diagnosed with kidney stones?
Yes
No
14.) Do you suffer from eczema or psoriasis?
Yes
No
15.) Do you experience frequent bloating?
Yes
No
16.) Do you feel you have dry skin and/or dry or brittle hair?
Extremely
Moderately
None
17.) Do you regularly suffer from heartburn or GERD (Gastroesophageal Reflux Disease)?
Yes
No
Not Sure
18.) Have you been diagnosed with high blood pressure or high cholesterol?
Yes
No
19.) Do you experience chronic inflammation (joints, back), chronic headaches, or arthritis?
Yes
No
If yes, please specify:
20.) What is your daily stress level?
Extreme
Moderate
None
21.) Approximately how many hours of sleep do you get per night?
Less than 5
5-6
7-8
8 or more
22.) Do you wake feeling rested?
Yes
No
223) Do you experience occasional or chronic fatigue?
Daily
3-5 times per week
None
24.) Do you exercise on a regular basis?
None
Once a week
2-3 times a week
4 or more times a week
25.)Have you ever done a detox?
Yes
No
26.) Is a detox something you would consider?
Yes
No
27.) Do you work in an environment that is well ventilated (open windows, Hepa filter, etc.)?
Yes
No
Moderately
28.) How would you describe your concentration/memory?
Excellent
Good
Fair
Poor
29.) Have you experienced a significant amount of weight gain recently, or are you currently trying to lose weight?
Yes
No
30.) Do you smoke regularly or live in a household with a smoker, or have exposure to secondhand smoke?
Yes
No
No, but I used to smoke
31.) If yes, are you considering trying to quit?
Yes
No
N/A
WOMEN ONLY
32.) Do you frequently experience symptoms of Premenstrual Syndrome (PMS) such as bloating, breast tenderness, irritability, or mood swings?
Yes
No
Unknown
33.) Are you pregnant or breast-feeding?
Yes
No
34.) Are you currently experiencing any uncomfortable symptoms of menopause, such as hot flashes, dramatic mood swings and insomnia?
Yes
No
Unknown
35.) If Yes, are your symptoms of menopause accompanied by heavy menstrual bleeding?
Yes
No
N/A
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FAMILY HISTORY
The choices you make in your daily life have the most influence of your health, however, genetic factors also play a part in determining risks of some health concerns and in the supplements you need to achieve optimum wellness.
Did or does anyone in your immediate family have heart disease (coronary artery disease) or has a female member under the age of 65 or a male family member under the age of 55 had a heart attack?
Yes
No
Unknown
Did or does anyone in your immediate family have colon cancer?
Yes
No
Unknown
Did or does anyone in your immediate family have Alzheimer"s disease?
Yes
No
Unknown
Did or does anyone in your immediate family have osteoporosis or hip fracture?
Yes
No
Unknown
Did or does anyone in your immediate family have breast cancer?
Yes
No
Unknown
MEDICATION
If you are currently taking prescription or over-the-counter (OTC) medications, please complete this section very carefully and check all that apply.
Heart Medications / Cholesterol-lowering Medications:
Statins (such as Lescol, Lipitor, Zocor, Provachol, Mevacor, Crestor, Altocor)
Anti-Arrythmic Medications (such as Digoxin / Lanoxin, Cordarone, Mexitil, Pacerone)
Antidepressants:
MAO Inhibitors (such as Nardil, Parnate, Marplan)
SSRI"s (such as Celexa, Prozac, Paxil, Zoloft, Sarafem, Selafemra, Prozac Weekly, Pexeva, Paroxentine Hydrochloride ER, Paxil CR, Luvox, Lexapro)
Tricyclic Agents (such as Elavil, Tofranil-PM, Tonfranil, Endep, Vanatrip, Aventyl Hl, Pamelor, Anfranil, Norpramin, Asendin, Vivactil, Surmontil)
SSNRI"s (such as Effexor, Effexor XR, Venlafaxine Hydrochloride, Cymbalta, Pristiq)
Tetracyclic"s (such as Remeron, Ludiomil)
Anxiolytic"s (such as Silenor, Adapin, Sinequan)
Anticoagulants (blood thinners):
Coumadin, Warfarin, Heparin
Aspirin
Anti-anxiety Medications:
Ativan, Librium, Valium, Xanax, or other anti-anxiety medications
Gastrointestinal Agent:
Heartburn or Ulcer Medication (such as Prevacid, Prilosec, Pepcid, Tagamet, or Zantac)
Over-the Counter Antacids:
Aluminum/Magnesium-containing (such as Maalox, Mylanta)
Calcium-containing (such as Tums or Rolaids, Prilosec)
Bismuth-containing (such as Pepto Bismol)
Zantac, Zantac 150
Analgesics and Narcotics as part of a daily or weekly regimen:
NSAIDs (such as Advil, Ibuprofen, Motrin, Naproxen, Aspirin)
Opiates or Opiate/Acetaminophen combinations (such as Vicodin)
Acetaminophen (Tylenol or similar products)
Digestion Stimulating Medications:
Cisapride, Propulsid, or other digestion stimulating medications
Diabetic Medications:
Iletin Regular, DiaBeta, Micronase, Prcose, Amaryl, Avandaryl or any other blood sugar regulating medication
Insulin
Steroids:
Inhaled Steroids (such as Asmacort)
Systemic Steroids (such as Prednisone)
Immune Suppressing Medications:
Azathioprine, Cyclosporine
Sleeping Medications:
Ambien, Lunesta, Restoril, Ativan, Serax or other sleeping medications
Other:
Theophyllines (such as Theo-Dur or Theophyl)
Cinemet (or other Parkinson"s medication)
Birth Control
Hypothyroid Medication (Synthroid, Levothyrox, Dessicated thyroid)
Hyperthyroid Medication (Tapazole, Northyx)
Please list any other medications you are taking but were not specified above:
Please list any Vitamin/Mineral/Herbal supplements that you are currently taking:
*
Please list any conditions that have been diagnosed by your physician but were not mentioned in the questions above. (Thyroid, surgery procedures, asthma, bladder infections, etc.)
Submit
Should be Empty: