Spiritweaverinc@hotmail.com
Dr Susan Janssens
General Health Questionnaire

General Health Questionnaire

Comprehensive Patient Questionnaire

  • Children

  • AgeSex 
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  • PhysicianFirst & Last NameContact Number 
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  • Current Health Professionals

    List of Health Professionals you currently see
  • First & Last NamePracticeContact Number 
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  • Current health conditions you desire improvement in and length of time they have been a concern to you, placed in order of importance

  • Health ProblemLength of Time 
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  • Family History

    Check the box if there is a family history for the following health problems. If the health condition resulted in a family member death, please mark the third column with DC.
  • No/YesHealth IssueFamily History 
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  • Past Medical History

  • HospitalisationYearReason 
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  • Childhood Illnesses

    Health as a Child (1:poor to 10:excellent). If less than 8 please explain.
  • RatingIllnessExplanation if less than 8 
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  • Type/Year/Adverse Reactions

  • Allergies

    List all known
  • AllergyItemsReaction 
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  • Pets

  • KindHow Many 
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  • Medication

    Prescription & Over-the-Counter
  • MedicationDoseHow LongFor What 
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  • Supplements

    Non-Prescription/Herbal/Nutritional/Any over-the-counter items
  • SupplementDosageHow Long on Supplement 
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  • General Anesthetic

    Have you ever had general anesthetic?
  • If yes, how long? 
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  • Antibiotics

    Have you been on antibiotics?
  • Yes/NoIf yes, when and how long? 
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  • Dental

    To the best of your knowledge please list all dental work/treatments you have undergone. Include fillings (specify type), pulled teeth, root canals, bridges, crowns, dentures, braces, retainer/splints, accidents/injuries or any other type of dental/jaw surgery
  • DateDentist NameTreatment 
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  • NoIf yes, when? 
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  • Chemicals

    Please list any current or past exposures to solvents, chemicals, cleaning agents, insecticides, herbicides, pesticides, chemical/metal vapors and/or dry cleaning agents
  • ItemWhenHow LongWhere 
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  • Travel

    List back country & third world trips
  • CountryTravel DatesIllness or Trauma 
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  • Lifestyle

  • YesIf no, why? 
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  • 0: All Work - 10: All Play
    0 
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  • Physical Fitness

  • Hobbies

    Please list your hobbies or recreational interests

  • Support/Stressors & Personal Growth

  • Please list the stress factors that affect you the mostPlease list the people/areas that support you the most 
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  • Select one or more by adding a row (+)
    MeditateHow Often/Describe 
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  • Smoking

    Select one or more by adding a row (+)
  • ProductHow OftenHow long have you been smoking?Quit. When? 
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  • Drinking

    Select one or more by adding a row (+)
  • ProductHow OftenHow long have you been drinking?Quit. When? 
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  • Diet

    For each ‘yes’ list type, serving size & frequency
  • TypeYes/NoServing size/Frequency 
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  • BreakfastTimeFood/Drink 
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  • LunchTimeFood/Drink 
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  • DinnerTimeFood/Drink 
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  • Snacks/DesertTimeFood/Drink 
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  • DrinksN/AFood/Drink 
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  • CravingsN/AFood/Drink 
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  • AversionsN/AFood/Drink 
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  • More than one choice enabled

  • Symptom Review

    Please complete the following section as thoroughly as you can. For every question that you answer “yes” or “ past”, please explain your answer further on the accompanying line.
  • WeightKg or PoundsReason 
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  • Weight 1 Year AgoKg or PoundsReason 
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  • Maximum WeightKg or PoundsReason 
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  • WhenKg or PoundsReason 
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  • Heightcm 
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  • Date : Last PhysicalDate : Last Blood Work 
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  • Energy

  • If Yes, click the time(s) of day you feel is/are best or worst for you
    YesYes, best time of dayYes, worst time of day 
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  • Sleep Patters

    Select one or more by adding a row (+)
  • Sleep WellYes/NoExplanation 
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  • Average hours of sleep per nightHoursExplanation 
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  • Sweating

    Select one or more by adding a row (+)
  • Night SweatsYes/No/PastSpecify 
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  • Skin

    Select one or more by adding a row (+)
  • EczemaYes/No/PastSpecify 
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  • Head

    If yes or past, please explain below
  • No/YesHeavy (If yes, please specify)Specify (If yes, please elaborate) 
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Eyes

    If yes or past, please explain below
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Ears

    If yes or past, please explain below
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Nose & Sinuses

    If yes or past, please explain below
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Mouth & Throat

    If yes or past, please explain below
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Respiratory/Chest

    If yes or past, please explain below
  • No/YesArea of PainSpecify (If yes, please elaborate) 
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  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Heart

    If yes or past, please explain below
  • No/YesSpecify (If yes, please elaborate) 
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  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Digestion/Abdomen

    If yes or past, please explain below
  • No/YesSpecify (If yes, please elaborate) 
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  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Do You Prefer
  • No/YesIf yes, describeTaste/Feeling in Mouth 
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  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Do these symptoms occur ...
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Bowel Function

  • TimesPer Day/Per WeekUsual TimeConsistency of Bowel Movements 
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  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Urinary Function

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Circulation

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Neurological

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Sexual Function

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Female Reproduction

  • Age Menses BeganDate of Last MenstruationNo of days of Menstrual FlowLength of Complete CycleRegular Self Breast Exam 
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  • Date & Results of last PAPAbnormal PAPNo of PregnanciesNo of Live BirthsNo of MiscarriagesNo of Abortions 
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  • Sexually ActiveBirth ControlSpotting Between PeriodsAre Cycles Regular 
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  • Pain During IntercourseCramps/Period PainsAre Cycles Regular?Abnormal Vaginal Discharge 
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  • Vaginal InfectionsMenstrual FlowColour of FlowConsistency of Flow 
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  • Multiple selection option
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Male Reproduction

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Risk of Infection

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Emotional

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Musculoskeletal

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Miscellaneous

    Select one or more by adding a row (+)
  • Health IssueNo/Yes/PastSpecify (If yes or past, please elaborate) 
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  • Stressors & Symptoms

    Using the timeline below, list the stressors (surgery, accidents/injury, change in work/residence/relationships, births, loss, mental/emotional stress etc) and symptoms (pain, digestive concerns, fatigue, headaches, allergies, menstrual changes, behavior/mood changes, etc)
  • Pre-NatalBirthChildhoodAdolescenceAdulthood 
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  • Pre-NatalBirthChildhoodAdolescenceAdulthood 
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  • Neurotransmitter Questionnaire

    In the questionnaire that follows, read each statement and score it in the margin as follows: * 0 points if this statement is not true at or does not apply to you. * 1 point if the statement is true a lot of the time and/or is affecting the quality of your life. Please respond to all questions as though you were not taking any medications or supplements.


    Please prove you are human by selecting the key.