EDEN DETOX HEALTH SPA QUESTIONNAIRE
GENERAL INFORMATION
Date    
Name*    
Age
Sex
 Male Female
Place of birth
Birth Date
Marital status Single Married Divorce
Number of children
Living situation alone family friends    
Occupation    

EMERGENCY CONTACT

    
Emergency Contact Name *    
Relationship    
Phone*    
OPTIONAL(sometimes it can help explain your health problem)    
Religion
Race
       
COMPREHENSIVE HEALTH HISTORY
There are many questions, please be patient and complete them all. It helps us to help you.
YOUR CURRENT HEALTH PROBLEMS    
What is your major health problem?    
What are the symptoms? (Location, quantity, quality, or severity, timing, setting in which they occurred, factors that aggravate them or relieve them and associated manifestations.)    
When did it start for the first time and setting in which it developed?    
Describe any factors that you suspect may have played a role in its onset and continuation.    
Is it becoming better or worse? Be specific in your description.    
Describe past treatments for this problem.    
Drugs: Which, how long and what dosage taken?    
Surgeries:
   
Natural treatments:    
What treatment worked the best?    
What treatment worked the least?    
Do you have any other health problems? Please list in order of importance and describe.    
Do you have any emotional issues that you would like to address?    
Do you have any sexual issues that you would like to address?    
Do you have any social issues that you would like to address?    
Do you have any family issues that you would like to address?    
Are you currently working with      
a doctor of conventional medicine yes no    
a naturopathic doctor yes no    
a counselor, pastor, or other therapist yes no    
Today's weight
Today's height
As an adult what has been your maximum weight?
and minimum
Any recent weight change?    
Do you feel weakness or fatigue? Explain    
Do you have an exercise routine? Describe.    
YOUR HEALTH HISTORY
      
Is your present state of health excellent good average fair poor
General state of health: rate today's state compared to the past. (Rate from 1 to 10; 1 is the lowest, 10 is highest.)
Now In the past Please comment.
When during the day is your energy the best?
Worst?
Rate your energy level: Now
In the past
Childhood illnesses: mumps
 rubella measles cough whooping
  chicken pox polio scarlet fever rheumatic fever
Childhood immunizations and age tetanus
pertussis diphtheria hemophilus influenza
at immunization: measles rubella mumps pneumococcal vaccine
  hepatitis B polio influenza  
List adult illnesses, psychiatric illness, accidents, and injuries, operations, and hospitalizations by date of onset, starting with the oldest first:
   
Do you have any allergies to drugs, herbs, foods, animals, dust or other?    
Have you been exposed to environmental hazards at home or on the job?
(Please read "Where do you find heavy metal toxicity?" at the end of this questionnaire and mention situations where you may have been exposed to mercury, cadmium, or lead.) 		   
Do you live in a new place or an old one?    
How long have you lived there?    
Is it damp and moldy, or dry?    
Do you have new wall to wall carpeting?    
Do you use aluminum cook pots?    
Do you have an air filter at home?
At your job?
Do you live in a city, a suburban area, or in the country?    
Do you live near a golf course or any area that is heavily sprayed with pesticides?    
Do you work in the presence of toxic fumes or chemicals?    
Do any of your hobbies involve toxic materials?    
Are you presently exposed to secondhand smoke?
In the past?
If yes, for how long?    
What is the source of your drinking water?    
Do you have any silver-mercury fillings?
How many?
What are your leisurely activities? Describe type and frequency.    
What is the quality of your sleep? How many hours of sleep do you get on average?
   
Current medications, amount and dosage:    
Vitamins, herbal remedies, and supplements:    
Do you smoke tobacco?
Have you smoked in the past? How long? How much?
Do you drink alcohol?
Have you drunk in the past? How long? How much?
FAMILY HISTORY      
Age and health of parents, and if deceased, cause of death    
Mother
    
Father    
Brothers    
Sisters    
Mother's mother    
Mother's father    
Father's father    
Father's mother    
Family history of (indicate family member, severity, or death)  
  diabetes arthritis mental illness drug addiction
  allergies anemia tuberculosis heart attack
  high BP epilepsy depression hypoglycemia
  cancer stroke headache alcoholism
Health of your children?    

DIGESTION AND ELIMINATION

    
Gastrointestinal      
Do you have any problem with gas, bloating, or fullness after eating? Yes No    
How Often?    
How severe is the problem? (Rate 1 to 10)    
How long have you had this problem?    
How often do you have a bowel movement?    
Do you ever have blood, mucous, undigested food, or black stools?    
Any rectal itching?    
Do your stools tend to be formed or loose?    
Do you have diarrhea, constipation, alternating diarrhea and constipation?    
Do you have thin, long, narrow stools?
How often?
Do you have small, hard stools?
How often?
How often do your stools have a strong disagreeable odor?    
Have you ever fasted?
For how long?
Was it supervised, or did you fast by yourself?    
Have you traveled outside of your country in the last 5 years?    

Have you gone camping in the last 5 years?

   
Kidneys and Bladder      
Have you had recurrent bladder infections?    
How were they treated?    
Do you have any burning sensation during or after urination?    
Is your urine dark yellow bright yellow pale yellow cloudy clear
Does your urine have a strong odor to it?    
Do you perspire when you exercise? lightly moderately heavily
Does your perspiration have a strong odor to it?    
MEDICAL SYMPTOMS RATING SCALE:    
Rate each of the following symptoms according to the following scale:
0 never or almost never have this symptom
1 occasionally have it, effect is not severe
2 occasionally have it, effect is severe
3 frequently have it, effect is not severe
4 frequently have it, effect is severe
     
HEAD
0 1 2 3 4 : headaches
0 1 2 3 4 : faintness
0 1 2 3 4 : dizziness
0 1 2 3 4 : insomnia
Total 		EYES
0 1 2 3 4 : watery or itchy
0 1 2 3 4 : swollen, reddened, or sticky eyelids
0 1 2 3 4 : bags or dark circles under eyes
0 1 2 3 4 : blurred or tunnel vision
Total
EARS
0 1 2 3 4 : itchy ears
0 1 2 3 4 : earaches or ear infections
0 1 2 3 4 : drainage from the ears
0 1 2 3 4 : ringing or hearing loss
Total 		NOSE
0 1 2 3 4 : stuffy nose
0 1 2 3 4 : sinus problems
0 1 2 3 4 : hay fever
0 1 2 3 4 : sneezing attacks
0 1 2 3 4 : excessive mucus formation
Total
MOUTH AND THROAT
0 1 2 3 4 : chronic coughing
0 1 2 3 4 : gagging, frequent need to clear throat
0 1 2 3 4 : sore throat, hoarseness, loss of voice
0 1 2 3 4 : swollen or discolored tongue, gums, or lips
0 1 2 3 4 : canker sores
Total 		SKIN
0 1 2 3 4 : acne
0 1 2 3 4 : hives, rashes, dry skin
0 1 2 3 4 : hair loss
0 1 2 3 4 : flushing, hot flashes
0 1 2 3 4 : excessive sweating
Total
HEART
0 1 2 3 4 : irregular or skipped heart beat
0 1 2 3 4 : rapid or pounding heart beat
0 1 2 3 4 : chest pain
Total 		LUNGS
0 1 2 3 4 : asthma and/or bronchitis
0 1 2 3 4 : chest congestion
0 1 2 3 4 : shortness of breath
0 1 2 3 4 : difficulty breathing
Total
DIGESTIVE TRACT
0 1 2 3 4 : nausea and/or vomiting
0 1 2 3 4 : diarrhea
0 1 2 3 4 : constipation
0 1 2 3 4 : bloated feeling
0 1 2 3 4 : belching, passing gas
0 1 2 3 4 : heartburn
0 1 2 3 4 : intestinal and/or stomach pain
Total 		JOINTS AND MUSCLES
0 1 2 3 4 : pain or aches in joints
0 1 2 3 4 : arthritis
0 1 2 3 4 : stiffness or limitation of movement
0 1 2 3 4 : pain or aches in muscles
0 1 2 3 4 : feelings of weakness or tiredness
Total
ENERGY AND ACTIVITY
0 1 2 3 4 : feelings of fatigue or sluggishness
0 1 2 3 4 : feelings of apathy or lethargy
0 1 2 3 4 : hyperactivity
0 1 2 3 4 : restlessness
Total 		MIND
0 1 2 3 4 : poor memory
0 1 2 3 4 : confusion, poor comprehension
0 1 2 3 4 : poor concentration
0 1 2 3 4 : poor physical condition
0 1 2 3 4 : difficulty making decisions
0 1 2 3 4 : stuttering or stammering
0 1 2 3 4 : slurred speech
0 1 2 3 4 : learning disabilities
Total
EMOTIONS
0 1 2 3 4 : mood swings
0 1 2 3 4 : anxiety, fear, nervousness
0 1 2 3 4 : anger, irritability, aggressiveness
0 1 2 3 4 : depression
Total 		OTHER
0 1 2 3 4 : frequent illness
0 1 2 3 4 : frequent or urgent urination
0 1 2 3 4 : genital itch or discharge
Total
GRAND TOTAL