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MSM-Australia
Taking a Dry Blood Sample
Pre-Consultation Questionnaire
Please answer all the questions below and then click the "SUBMIT" button at the bottom of the page.
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Blood Type (if known)
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SELECT ONE
0
A
B
AB
On a scale of 1 - 10 how do you rate your health and vitality right now? (1 being flat on your back, 10 being walking on air).
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Please Select
1
2
3
4
5
6
7
8
9
10
Email
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Weight (Kgs)
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Are you on any medications? If so, please note here ...
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Pre-existing conditions
Please list any pre-existing health conditions, health concerns, symptoms or any other relevant information that might be of help with this assessment
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Do you suffer from vertigo (a specific kind of dizziness - a sense that you, or your environment, is moving or spinning, even though there is no movement)?
*
Please Select
YES
NO
Do you suffer from depression?
*
Please Select
YES
NO
Do you suffer from general fatigue?
*
Please Select
YES
NO
Do you suffer from insomnia?
*
Please Select
YES
NO
Do you have cravings?
*
Please Select
YES
NO
Do you suffer cramps?
*
Please Select
YES
NO
Do you suffer hypertension?
*
Please Select
YES
NO
Do you have poor circulation?
*
Please Select
YES
NO
Do you suffer cardiovascular disease?
*
Please Select
YES
NO
Do you normally have a high body temperature?
*
Please Select
YES
NO
Do you have polyuria (excessive or abnormally large production or passage of urine)?
*
Please Select
YES
NO
Do you find it hard to wake up in the morning?
*
Please Select
YES
NO
Do you suffer from anxiety?
*
Please Select
YES
NO
Do you normally have a low body temperature?
*
Please Select
YES
NO
Do you have olyguria (low output of urine)?
*
Please Select
YES
NO
Do you often have soft / loose stools?
*
Please Select
YES
NO
Do wake up in the morning easily?
*
Please Select
YES
NO
Are you slow to heal?
*
Please Select
YES
NO
Do you get migraines?
*
Please Select
YES
NO
Do you suffer from muscle loss?
*
Please Select
YES
NO
Do you suffer from weight issues?
*
Please Select
YES
NO
Do you get irritable when hungry?
*
Please Select
YES
NO
Do you have type II diabetes?
*
Please Select
YES
NO
Are your hands normally warm and dry?
*
Please Select
YES
NO
Are your fingers warmer than your triceps?
*
Please Select
YES
NO
Do you suffer from asthma?
*
Please Select
YES
NO
Do you suffer from allergies (not food)?
*
Please Select
YES
NO
Are your hands normally cold?
*
Please Select
YES
NO
Are your fingers colder than your triceps?
*
Please Select
YES
NO
Is your mouth normally dry?
*
Please Select
YES
NO
Do you suffer from food allergies?
*
Please Select
YES
NO
Do you suffer from shortness of breath
*
Please Select
YES
NO
Do you suffer from chronic fatigue?
*
Please Select
YES
NO
Do you suffer from sleep apnea?
*
Please Select
YES
NO
Do you normally suffer from arthritic issues?
*
Please Select
YES
NO
Approximately how many litres of water do you drink per day (not including coffee / tea / soft drinks etc?
*
Please Select
0.5
1
1.5
2.0
2.5
3
3.5
4
4.5
5
Over 5
Do you drink coffee regularly?
*
Please Select
YES - 1 Cup per day
YES - 2 Cups per day
YES - 3 Cups per day
YES - More than 3 Cups per day
I don't drink coffee
Do you drink alcohol on a regular basis?
*
Please Select
YES
NO
Do you smoke tobacco?
*
Please Select
YES
NO
How much salt do you normally add to your food or water each day?
*
Please Select
I don't eat salt
0-5 grams
5-10 grams
10-15 grams
over 15 grams
What type of salt do you normally use (normal table salt / Celtic sea salt / Himalayan pink salt etc.)
*
Do you take recreational drugs?
*
Please Select
YES
NO
Do you normally drink water / alcohol / other drinks with your meals?
*
Please Select
YES
NO
What is normally your first drink of the day?
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Do you normally drink your first drink of the day before you eat any food?
*
Please Select
YES
NO
Please list any other drinks you would normally drink each day
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How many hours of sleep do you normally get each night
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
How often do you exercise?
*
Please Select
Daily
Weekly
Monthly
I don't usually exercise
What type of exercise do you do?
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Please list any supplements you are taking and why you are taking them.
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Do you normally eat breakfast?
*
Please Select
YES
NO
Please list foods you would normally eat for breakfast?
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Do you normally eat lunch?
*
Please Select
YES
NO
Please list foods you would normally eat for lunch
*
Do you normally eat tea / evening dinner?
*
Please Select
YES
NO
Please list foods you would normally eat for tea / evening dinner?
*
Do you normally eat supper?
*
Please Select
YES
NO
Please list foods you would normally eat for supper
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On a scale of between 1 an 10 (1 being very poor and 10 being excellent), how would you rate your current emotional wellbeing?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Do you frequently pass gas after meals?
*
Please Select
YES
NO
Do you suffer from reflux or heartburn
*
Please Select
YES
NO
Do you often burp after meals or feel bloated? (Even just small burps.)
*
Please Select
YES
NO
Does your meal ever feel like it's sitting in your stomach like a rock for too long?
*
Please Select
YES
NO
Do you crave sweet or salty foods?
*
Please Select
YES
NO
Do some foods make you nauseous?
*
Please Select
YES
NO
Is your stool sometimes lighter than the colour of corrugated cardboard?
*
Please Select
YES
NO
Do you have regular (daily) bowel movements?
*
Please Select
YES
NO
How many bowel movements do you have a day / week (please specify)?
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Do you ever experience heartburn or acid reflux
*
Please Select
YES
NO
Have you recently taken any antacids or acid reflux medications?
*
Please Select
YES
NO
Are you frequently constipated?
*
Please Select
YES
NO
Do you frequently experience diarrhoea or a loose stool?
*
Please Select
YES
NO
Do you have a stomach ulcer?
*
Please Select
YES
NO
Does eating meats or fats restore your energy?
*
Please Select
YES
Sometimes
NO
Have you had your gallbladder removed?
*
Please Select
YES
NO
Do you ever see undigested food in your stool?
*
Please Select
YES
NO
Do you seem to gain weight no matter what you eat?
*
Please Select
YES
NO
Do cravings frequently derail your weight loss attempts?
*
Please Select
YES
NO
Submit
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