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HEALTH &MEDICAL
INFORMATION

GENERAL HEALTH QUESTIONNAIRE
NUTRITIONAL QUIZ
MEDICAL HISTORY

GENERAL HEALTH QUESTIONNAIRE

OVERALL WELL-BEING

Name:		Phone
Email		List any negative health symtoms your'e experiencing

Do you have chronic inflammation in your body?

If you answer “Yes” to 3 or more questions you may have Chronic Inflammation.

Do you have elevated cholesterol or triglycerides?	yes	no
Do you have numbness or tingling in your arms or legs?	yes	no
Do you eat meat, commercially bakes sweets, fried foods or use vegetable oil daily?	yes	no
Do you consume fish less than two times per week?	yes	no
Do you have high blood pressure, asthma or colitis?	yes	no
Do you smoke?	yes	no
Do you have gingivitis, periodontal disease or not have regular dental cleanings and check-ups at least every six months?	yes	no

POOR NUTRITION AND LIFESTYLE

Do you have poor nutrition and digestion?

If you answer “Yes” to 4 or more questions you may have Poor Nutrition and Digestion

Do you regularly include fast food in your diet (three or more times per week)?	yes	no
Do you experience belching, bloating or persistent fullness soon after eating, or do you experience excess gas often?	yes	no
Do you experience heartburn or acid reflux two or more times per week?	yes	no
Are you allergic to any specific foods?	yes	no
Do you feel fatigued or lethargic after eating?	yes	no
Do you commonly have bad breath or a bad taste in your mouth?	yes	no
Do you use digestive aids such as laxatives, antacids or acid-blocking drugs?	yes	no
Do you often feel “older” than you should for your age?	yes	no
Does your skin look sallow, gray, puffy, wrinkled or aged?	yes	no

EXPOSURE TO TOXINS?

Is Your Detoxification Capacity Impaired?

If you answer “Yes” to 4 or more questions your body needs help to detoxify.

Do you become physically ill when exposed to strong smells (perfume, auto exhaust, cigarette smoke, etc.)?	yes	no
Do you use chemical cleaners or solvents at home, at work or in your hobbies?	yes	no
Do you live in a house/apartment or work in an office less than five years old?	yes	no
Do you have any amalgam (mercury) dental fillings?	yes	no
Are you prone to side effects from medication or supplement, or do you become more sensitive to the effects of alcohol?	yes	no
Do you smoke?	yes	no
Do you have or have you ever had breast implants?	yes	no
Do you have any pets, especially dogs, cats, birds or other furred or feathered animals?	yes	no
Do you wake up often during the night to urinate?	yes	no

Is Your Home and/or Work Environment Toxic?

If you answer “Yes” to 4 or more questions your Home or Office needs a “Health Makeover.”

Do you have carpet in your home?	yes	no
Do you vacuum less than three times per week?	yes	no
Have you changed or cleaned your air filters in the past 30 days?	yes	no
Do you routinely drink tap water?	yes	no
Are your clothes and bedding washed in unfiltered city water?	yes	no
Have you recently repainted your home on the inside?	yes	no
Have you noticed any black spots or mold on your air vents or walls?	yes	no
Have you had your air vents cleaned in the past year?	yes	no
Do you use natural cleaning agents or chemical-based cleaners in your home?	yes	no
Do you use chemical fertilizers, insecticides or pesticides?	yes	no
Does your home contain a quality air purification system?	yes	no

ProPilates is not intended to treat, cure, or prevent any disease. The information provided is intended for educational purposes. It is not to be construed as providing medical advice or substitution for professional services. All information provided is general and not specific to individuals. We endeavor to state the case properly and educate our associates appropriately. ProPilates does not, in any way, represent treatment, cure or mitigation of disease. Persons experiencing health problems should consult a medical professional.