Health and Nutrition Questionnaire

This questionnaire will enable me  to send you a detailed recommendation for your better health based on your condition. This service costs $50 unless you are buying the full Recovery Kit in which case it is included in the price of the kit.

This life-style and nutrition evaluation is intended only for educational purposes and to assist an individual in learning how to preserve his or her own health in harmony with natural health principles. 

It is not the intention of this evaluation to diagnose or to prescribe any medication, treatment or modality for any physical or mental disorder, disease or ailment, complaint or abnormality.

Disclaimer:

Please be aware that I am not a medical doctor,  however  I have been ordered to heal the sick using the life style approach which was given to me by God. 

I cannot be held responsible or liable for the use or misuse of this information for God has declared that he alone is responsible for the results when we obey his commands. Therefore, your pursuance of the recommendations herein will be construed as an unwritten contract between you and God in which you commit to following his plan, leaving the results with Him, and he promises to heal you if by doing so He will be glorified.

Please complete entire questionnaire and return for review. After careful evaluation, suggestions will be outlined for you in your search for better health using God's Plan.

Please fill in the questionnaire  and submit. The recommendation will be sent to you via email  or alternatively if you are buying the Kit - we will include a typed version with your package.

You may just purchase the recommendation without the kit if preferred. Please email for bank details after you have hit the submit button below. Once your transfer has been received we will email your reply

 

The Questionnaire

Providing the following information will allow a better understanding of your condition and enable us to help you more. Explain fully where necessary. 

Last Name:    First Name:

Date of Birth:                        Age:   

Address:

Country:   

 Email:

Phone:       Fax:   

Cell:

Gender:       Height:                   

Weight:        Weight one year ago: 

Nationality:

Religious Preference:     

Marital Status:

 

MEDICAL HISTORY

Give medical history - names and dates of past ailments, operations (anything you feel is significant, including past complaints.

When did you last consult a physician?

For what reason?

What are you currently being treated for? 

What specific condition(s) would you like this consultation to address?

List all medicines, pills or drugs you are taking now, how many you are taking of each and how often do you take them ? eg: 2 Zantac capsules, 3 times daily with each meal

List minerals, herbs and.or vitamin supplements are you taking, how many you are taking and how often you are taking them?

Do you have indigestion?     Gas?        Bloating  ?      

What foods tend to cause indigestion, bloating or gas?  

How often do you have bowel evacuations  ?                 

Describe colour and texture of stool 

Do you have diarrhoea?       Constipation?  

Do you wear eyeglasses?   Contact lenses?     

For how many years?  

Do you have or have you had any of the following? check the appropriate box and explain fully in the space that follows

Acne Digestive disorders Nervous disorder
Alcoholism Eczema Poliomyelitis
Allergies Emphysema Respiratory problems
Anemia Gallstones Rheumatic Fever
Appendicitis Hay Fever SKin Problems
Arthritis Headaches Sinusitus
Asthma Heart Disease Tuberculosis
Cancer Hemorrhoids Tumors
Chills/cold skin Kidney stones Ulcers or Colitus
Depression Lumbago Sexual disorders
Diabetes Mental disorders HIV/AIDS

Explain fully the past or present ailments checked above:

Lifestyle

Occupation :    

What hours do you work?  

Health of Spouse:      if applicable

How many children do you have?       Ages : 

Health of your children:    

Recreational activities enjoyed :   

Hours per week viewing TV:         

Do you often feel guilty about past mistakes   

Do you worry about the future?       

Do you have stress ?       Depression  ?  

Check the following categories which cause stress:

Financial    
Job related
Getting along with people
Family (spouse or children)
Not happy with myself

On a scale of 1 to 10 rate your stress level ( 1 = very little stress and 10 = an extreme amount
of stress         

 Do you enjoy the work that you do?  

If not, explain 

Are you developing your mental and spiritual capabilities by daily studies, meditation and prayer ?


Are you involved with any type of activity in which you are helping other's? 

The following space is for those who would like to elaborate more on the causes of their stress, depression and other negative emotions

OPEN AIR

How many hours a day do you spend outdoors?

Do you sleep with your windows closed?  

Are you able to breathe fresh air while you are working? 

Is the building where you work constructed in such
 a way that the windows cannot be opened ?

Do you know how to do deep breathing exercises? 


If so, explain
 

DAILY EXERCISES

How often do you exercise?  

Describe the exercise:
 
 
How do you feel after you exercise (if applicable)?

SUNSHINE

How much time daily do you spend outdoors in the sunlight? 

Do you often get sunburnt ?    

Do you visit tanning beds   ?  

Are you afraid of getting skin cancer ? 

 

PROPER REST

What time do you get to bed?  

What time do you awaken?   

What time is your last meal before retiring?  

Do you snack just before bedtime?    

Do you wake up during the night and snack?   

If so, what do you eat?   

Do you have trouble sleeping?  

Explain:      

 WATER

How much water do you drink daily?  

What type (spring, distilled, filtered, tap etc)?   

Check below the beverages you drink and indicate how much of each
Coke            How many bottles or cups per day? 

Coffee          Number of cups per day  ?

Tea              Number of cups per day ?   

Fruit juice   Type and amount each day  ?

Beer           Type and amount per day ? 

Milk             Amount per day   ?      

Other          Type and amount  ?

What is the usual color of your urine? 

Do you understand the principles of hygiene? 

Explain  

 ALWAYS TEMPERATE

Do you ingest caffeine in any form? 
If so, for how many years?  
Have you ingested caffeine in the past?   
For how many years?  
if so when did you stop?   
Do you smoke or chew tobacco?  (indicate which) 
If so for how many years?  
Have you used tobacco in the past?  
For how many years?   
If so, when did you stop?  
Do you drink alcohol?   
If so, what kind?  
For how many years?  
Have you drunk alcohol in the past? 
For how many years?  
If so, when did you stop?  
Do you overwork?  
How many hours of tv do you watch every week? 

NUTRITION

Do you overeat? 
Do you feel stuffed after your meals? 
Do you eat between meals?  
Explain  
Do you drink with your meals  
If so, what liquids?  
Do you wear removable dentures or plates?  
Do you eat fast?  
How long does it take to eat?   
Do you have a peaceful environment when you eat? 
Are you following any special diet?  
Do you have set meal times?   
Explain     

  
Do you eat animal products? 
Dairy products?   
Do you eat desserts, candy or other sweets regularly?  
Explain  

What time do you eat breakfast?  
What is your usual breakfast? 

What time do you eat lunch? 
What is your usual lunch? 

What time do eat supper? 
What is your usual super?  

Okay - that's all we need 

Date:  

Please indicate that you understand that this questionnaire and the educational information given in this consultation is not intended to diagnose or to treat any disease, ailments or abnormality, and that it serves merely as background information in order for us to ADVISE you on a healthier lifestyle according to your condition.

I understand and have read the disclaimer YES            NO

Please send an email chrisadvishealth@yahoo.com  to us letting us know your questionnaire is on it's way. We will send you our bank details for a transfer of $50. As soon as this is received we will email you a detailed advisory response to this questionnaire. If you are ordering the complete kit then this service is free.