Heart/Cardiovascular Disease often ranked the number one untimely killer of human life. Yet, it's so very preventable. This questionnaire helps clinicians screen for a variety of causes that all target and impact the heart/cardiovascular system.
The fields denoted with * are compulsory fields
* Name & Surname
* Telephone
* Email
For each statement that applies to you, enter a ' X '.
Existing Concerns
1.
Established Heart-Cardiovascular concerns: heart attack, atherosclerosis, high blood pressure, strokes, congestive heart, atrial fibrillation, irregular heartbeat, palpitations?
2.
Metabolic Syndrome: diabetes, obesity, too fat around the middle?
3.
Family History of mother or father with high blood pressure, heart attack, angina, stroke, heart disease, hardening of the arteries?
Lifestyle Concerns
4.
Sedentary lifestyle (work sitting down), not exercising much?
5.
Smoking: either in the past or now?
6.
History of exposure to tobacco smoke (parents smoked, work in nightclub, etc.)?
7.
Mood: Feelings of depression, on-going grief, apathy, loneliness, hopelessness, etc.?
8.
Emotional Control: easily angered, often frustrated, resentful, irritable, hostile?
9.
Sleep: less than 6 hours per night?
"Gut-Heart" Connection
10.
Experience (any) gas, pain, bloating, diarrhea, constipation, dry or foul smelling stools?
11.
Experience heart palpitations or irregular heartbeat after eating?
12.
Used oral antibiotics within the past year?
13.
Abdominal pain? Gas? Bloating? Diarrhea? Constipation?
14.
Intestinal inflammation? Colitis? Irritable Bowel? Diverticulitis/osis? Crohn's?
Metabolic Syndrome / Glucose Metabolism / Blood Sugar Connection
15.
Have a strong desire for sweets?
16.
Energy decline an hour after eating?
17.
Overweight? (Women: waist 35" or more. Men 40" or more)
18.
Elevated blood pressure? Cholesterol? Triglycerides?
Dietary Factors
19.
Eat fried foods more than once a month?
20.
Drink sodas, more than one soda a week?
21.
Eat sweets daily? Desserts? Breakfast cereals?
22.
Eat USA-grown wheat, breads, pasta?
23.
Eat USA-grown corn products? (85% is genetically-modified, contains pesticides)
Known Ailment Factors
24.
Gout?
25
Gum infections, periodontal disease, bleeding gums?
26.
Rheumatoid arthritis?
27.
Autoimmune concerns? (MS, Scleroderma, Sjögren's, etc.)
28.
Fibromyalgia, Chronic Fatigue?
29.
Asthma, allergies, hay fever rhinitis, sinus problems, hives, food sensitivities?
30.
Chronic Infections? Chlamydia? Epstein Barr? Cytomegalovirus?
31.
Recurrent colds? Poor immunity?
32.
Snoring? Sleep apnea?
33.
Kidney concerns (history of infections, or malfunctions?)
Stress Factors
34.
Death of a loved one in the past year?
35.
Divorce, separation of loved one in the past year?
36.
Major illness or surgery in the past year?
37.
Fired, let go, dismissed from employment in the past year?
38.
Move residence in the past year?
39.
Financial difficulties? Loss of lifestyle?
40.
Jail, or legal judgments against you?
41.
Family disputes? Worry regarding children?
42.
Overwhelmed with day-to-day responsibilities?
43.
Feel anxiety, stresses that elevate your heart rate?
44.
Panic attacks of anxiety?
45.
Sexual difficulties (Male: performance issues; Female: low desire, painful, unfulfilling)
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