Health Diagnosis Survey

Final Survay Form

Before you begin, please set aside 20-35 minutes to complete this survey. Your answers are essential in helping us form an accurate diagnosis, so please respond as thoroughly as possible. You’ll be guided through 12+ key categories to ensure a comprehensive assessment.

Let’s start your journey toward better health!

First Name

Last Name

Phone/Mobile

Main Problem

What is the main health concern that brought you here today?

When did you first notice this issue?

How does this problem affect your daily life?

What triggers or worsens your main symptom(s)?

Have you sought treatment for this issue before? If yes, what treatments?

Pain

Where do you experience pain, and how would you describe its location?

How would you describe the pain (sharp, dull, throbbing, stabbing, aching)?

Is the pain constant, or does it come and go?

When did you first notice the pain, and has it changed over time?

What makes the pain worse (e.g., movement, cold, heat, stress, certain foods)?

Food and Taste

How is your appetite? Have you noticed any changes recently?

Do you feel hungry often or rarely? Are you easily satiated?

Do you have cravings for specific foods (e.g., sweet, salty, spicy, sour)?

Do you have a preference for hot or cold foods in terms of temperature?

Does eating relieve or worsen any of your symptoms, such as pain or discomfort?

Stools

How often do you have bowel movements?

Is the consistency of your stool normal, hard, or loose?

Do you experience constipation or diarrhea, or does it alternate?

Do you have a regular schedule for bowel movements, or is it unpredictable?

Do you notice any undigested food in your stool?

Urine

How often do you urinate during the day?

Do you wake up at night to urinate? If yes, how often?

Is your urine clear, cloudy, or dark in color?

Do you experience pain, burning, or discomfort when urinating?

Do you feel an urgent need to urinate or difficulty starting the flow?

Thirst and Drink

How often do you feel thirsty throughout the day?

Do you prefer to drink hot, warm, or cold beverages?

Do you feel thirsty but have little desire to drink?

Do you drink large amounts at once or sip small amounts throughout the day?

Does your thirst change depending on the weather or season?

Energy Levels

How would you describe your energy levels throughout the day (constant, fluctuating, or generally low)?

Do you experience a noticeable drop in energy at specific times of day?

Do you feel more tired after meals or physical activity?

How long have you been feeling tired or fatigued, and when did it first start?

Do you experience any feelings of heaviness or sluggishness in your body?

Head

Do you experience headaches? If yes, how often?

Where is the headache located (forehead, temples, back of the head, whole head)?

What type of pain do you experience during headaches (dull, sharp, throbbing)?

Does the headache occur at specific times of the day?

What triggers or worsens the headache (e.g., stress, food, weather)?

Face and Body

Do you experience any pain or discomfort in your face?

Do you often feel a sense of heat or coldness in your face?

Have you noticed facial pain in specific areas, such as around the eyes, cheeks, or jaw?

Do you experience numbness or tingling sensations in your face?

Do you have any facial twitching or involuntary movements?

Chest and Abdomen

Do you experience any chest pain or tightness? If yes, where is it located?

Does the pain feel sharp, dull, or like pressure in your chest?

Do you have any difficulty breathing or feel short of breath?

Have you noticed palpitations or an irregular heartbeat?

Do you experience a feeling of fullness or oppression in your chest?

Limbs

Do you experience any pain, numbness, or tingling in your arms or legs?

Do you feel weakness or difficulty in moving your limbs?

Have you noticed any stiffness or limited mobility in your joints?

Do you experience swelling or puffiness in your hands, feet, or legs?

Is there a feeling of heaviness in your arms or legs?

Sleep

How would you describe the quality of your sleep (restful, disturbed, insufficient)?

Do you have difficulty falling asleep, staying asleep, or both?

How many hours do you sleep on average each night?

Do you wake up frequently during the night? If yes, what time do you usually wake up?

Do you experience vivid or disturbing dreams that affect your sleep?

Sweating

Do you sweat more than usual, or do you feel that you don’t sweat enough?

Do you sweat at specific times of day, such as in the morning or at night?

Do you experience excessive sweating on specific parts of your body (e.g., head, hands, feet)?

Do you sweat during sleep or wake up feeling sweaty?

Is the sweating associated with feelings of heat, or do you feel cold when sweating?

Ears

Do you experience ringing in your ears (tinnitus)? If yes, is it high-pitched or low-pitched?

Do you have any difficulty hearing or experience partial hearing loss?

Does the ringing in your ears get worse with stress, tiredness, or emotional upset?

Do you feel pressure or fullness in your ears?

Do you have ear pain or sensitivity to loud sounds?

Eyes

Do you experience any eye pain or discomfort (dryness, itching, burning)?

Do your eyes feel tired or strained, especially after reading or using screens?

Have you noticed any changes in your vision, such as blurriness, spots, or floaters?

Do your eyes water excessively, or do they feel dry and irritated?

Do you experience sensitivity to light or glare?

Feeling of Cold, Heat, and Fever

Do you often feel colder or hotter than others around you?

Do you experience cold hands and feet, even when the rest of your body is warm?

Do you feel cold all over, or is it localized to specific areas (e.g., lower back, abdomen)?

Do you feel cold more often in certain environments or seasons?

Do you feel a sensation of heat or warmth in your body, even when the environment is cool?

Emotional Symptoms

How would you describe your overall emotional state (calm, anxious, irritable, etc.)?

Do you experience frequent mood swings or feel emotionally unstable?

Do you often feel sad or depressed without a clear reason?

Do you have feelings of anger or frustration that are difficult to control?

Do you feel anxious, restless, or constantly worried about things?

Sexual Symptoms

Do you have a normal level of sexual desire, or has it changed recently?

Do you experience any discomfort or pain during sexual activity?

Have you noticed a decrease in sexual desire or libido?

Do you feel emotionally or physically drained after sexual activity?

For men: Do you experience erectile dysfunction or difficulty maintaining an erection?

Women’s Symptoms

How regular is your menstrual cycle (e.g., every 28 days, irregular, or missed periods)?

How long does your menstrual bleeding typically last?

Is your menstrual flow heavy, light, or moderate?

Do you experience any clots in your menstrual blood? If so, how large are they?

Do you experience pain before, during, or after your period? Where is the pain located?

Children’s Symptoms (For Parents)

Was the pregnancy with your child healthy, or were there any complications?

Was the child delivered naturally or through a C-section?

Did your child suffer from any traumas or health complications at birth?

Was the child breastfed, and for how long? If not, what formula was used?

When did your child begin weaning onto solid foods, and were there any reactions to foods?