• MARK JAMES GORDON

    Certified Detoxification Specialist, ISOD

  • Contact information:
    mark@markjamesgordon.com
    805-258-2357

    www.markjamesgordon.com

  • Health Questionnaire

    Member's Information - Please fill out as much as you can. It helps me greatly. All info is of course confidential and will not be shared voluntarily wiithout your permission.
  • Female-Male
  •  -

  • Vitals

  • Thyroid/Parathyroid (Glandular System)

  • Do you get cold hands and feet? (TD)
  • Is it easy to put on weight and hard to lose it? (TD)
  • Are your fingernails ridged, brittle or weak? (PD)
  • Do you have varicose or spider veins? (PD)
  • Do you, or have you had hemorrhoids or prolapsed organs? (PD)
  • Do you get cramping in your muscles? (PD)
  • Is your bladder strong or weak? (PD)
  • Do you have an irregular heartbeat? (PD)
  • Do you have Mitral Valve Prolapse (Heart Murmur)? (PD)
  • Do you get headaches or migraines? (PD)(UC)
  • Have you ever had a hernia? (PD)
  • Have you ever had an aneurysm? (PD)
  • Do you have osteoporosis? (PD)
  • Do you have scoliosis? (PD)
  • Do you get irritable easily? (PD) (AL)
  • Do you have low energy levels? (TD) (AL)
  • Do you suffer from symptoms of depression? (PD)
  • Did you score low on your bone density tests? (PD)
  • Do your tests come back showing low Calcium levels? (PD)
  • Do you have, or have you ever had, a goiter? (TD)
  • Do you have spine deterioration, herniated discs, or bone spurs? (PD)
  • Have you been diagnosed with Hashimoto or Reidel disease? Has a family member? (TD)
  • How much do you sweat? (TD)
  • Do your legs get tired or cramp after you walk? (PD)
  • Do you bruise easily? (PD)

  • Pancreas

  • Do you get gas after you eat? (PS)

  • Do you feel your foods just sitting in your stomach? (PS)
  • Do you have Acid Reflux? (PS)
  • Do you see any undigested foods in your stools? (PS)
  • Are you thin and have a hard time putting on weight? (PS) (TD)
  • Do your foods pass right through you (diarrhea)? (PS)
  • Do you have moles on your body? (Adrenal & Pancreatic weakness)

  • Adrenal Glands

  • Medulla (Adrenal)

  • Are you overweight? (ALM) (TD)
  • Do you have M.S., Parkinson's or Palsy? (ALM)
  • Do you have anxiety attacks, or feel overly anxious? (ALM)
  • Do you feel excessive shyness or inferior to others? (ALM)
  • Do you have tremors, nervous legs, etc.? (ALM)
  • Do you have High or Low Blood Pressure? (ALM)(KY)
  • Do you have hypoglycemia (low blood sugar)? (ALM)
  • Do you have Diabetes (high blood sugar)? (ALM)
  • Do you have tinnitis (ringing in the ears)? (ALM)
  • Do you have shortness of breath or is it hard to take a deep breath? (ALM)
  • Do you have a hard time sleeping or insomnia? (pineal)
  • Do you have Chronic Fatigue Syndrome? (ALM)
  • Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia? (ALM)
  • Do you have heart arrhythmias? (ALM)

  • Cortex (Adrenal)

  • Do you have elevated blood cholesterol levels? (ALC)
  • Do you have arthritis, bursitis, or any inflammatory issues? (ALC)

  • Do you have any "itis' (inflammatory conditions)? (ALC)
  • Do you have low steroids or cortisol levels? (ALC)

  • Females Only

  • Are your menstruation's irregular? (pituitary)
  • Do you get excessive bleeding during menstruation?
  • Do you have or have you had ovarian cysts? (ALC)
  • Do you have or have you had fibroids? (ALC)
  • Do you have or have you had endometriosis or A-typical cells? (ALC)
  • Do you have or have you had fibrocystic breasts? (ALC)
  • Do you get sore breasts, especially during menstruation? (ALC)
  • Do you have a low or excessive sex drive?
  • Have you had a hysterectomy?
  • Did they take any other organs out at the same time? (ie gallbladder)
  • Have you had a D & C?
  • Have you had a miscarriage?
  • Have you had a difficulty conceiving children?
  • Have you been on Birth Control Pills?
  • Are you currently pregnant?

  • Males Only

  • Do you have prostatitis (frequent urination esp. at night)? (ALC)
  • Do you have prostate cancer?
  • Do you have testicular hypertrophy (enlargement)? (ALC)
  • Do you have a low or excessive sex drive?
  • Do you have erection problems? (ALC) (ALM)
  • Do you have premature ejaculation?

  • Gastro-Intestinal Tract

  • Do you have gastritis or enteritis? (ALC)
  • Is your tongue coated (white, yellow, green, or brown), especially in the morning?
  • Do you have gastroparesis (paralysis)? (ALM)
  • Do you have a hiatus hernia? (PD)
  • Do you have colitis? (ALC)
  • Do you have diverticulitis? (PD)
  • Do you get or have diarrhea?
  • Do you get or have constipation? (ALM)
  • have you ever had stomach or intestinal ulcers? (PS)
  • Do you or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal, etc.) (ALC)
  • Do you have Crohn's Disease? (ALC)
  • Do you have "gas" problems? (PS)

  • Liver/Gallbladder/Blood

  • Do you have a problem digesting fats? (LG)
  • Do fats or dairy foods cause bloating and/or pain in the stomach area? (LG)
  • Are your stools white or very light brown in color? (LG, PS)
  • Do you get pain behind the right, lower rib area? (LG)
  • Do you have "liver" or brown spots on your skin? (not freckles) (LG)
  • Are you jaundiced (yellowing of the skin)? (LG)
  • Do you have any skin pigmentation changes? (LG, ALC)
  • Are you or have you ever been anemic? (SN, AL, LG)
  • Do you have, or have you ever had, hepatitis? (LG)

  • Heart and Circulation

  • Do you get chest pains or angina? (ILC, AL)
  • Have you ever had a heart attack (Myocardial Infarction)? (ILC)
  • Have you ever had open-heart surgery?
  • Do you have heart arrhythmia's? (ALM, PD)
  • Do you have a heart murmur or Mitral Valve Prolapse? (PD)
  • Do you ever feel pressure on your chest? (ILC)
  • Do you get "prickly" pains anywhere, especially in the heart area? (ILC, ANS)
  • Do you have, or have you ever had High Blood Pressure? (kidneys)
  • Do you have a Pacemaker or Stints?

  • Skin

  • Do you get or have skin rashes? (ILC)
  • Do you get skin blemishes? (ILC)
  • Do you have Eczema or Dermatitis? (ILC)
  • Do you have Psoriasis? (ILC)
  • Do you itch anywhere? (ILC)
  • Is your skin:
  • Do you get or have dandruff? (ILC, UC)
  • Do you have skin problems? (ILC)

  • Lymphatic System

  • Do you have hair loss or are you bald or going bald? (UC) (ILC)
  • Have you ever had lymph nodes removed? (ILC)
  • Do you have, or have you ever had, a goiter? (TD) (ILC)
  • Do you have any gray hair? (UC) (ILC)
  • Do you have a hard time remembering things? (UC) (ILC)
  • Do you ever get colds or flu-like symptoms? (ILC, UC)
  • Do you have fibromyalgia or scleroderma? (ILC)
  • Do you have sinus problems? (UC) (ILC)
  • Do you have or get sore throats? (UC) (ILC)
  • Do you have swollen lymph nodes? (ILC)
  • Do you have or have you had tumors? (ILC)
  • Type
  • Do you have a low platelet count (blood)? (SP,BM)
  • Is your immune system weak or sluggish? (ILC, SP)
  • Have you had appendicitis or an appendectomy? (ILC)
  • Do you get boils, pimples, cysts, etc.? (ILC)
  • Do you get regular exercise?
  • Have you ever had abscesses? (ILC)
  • Have you ever had toxemia? (ILC)
  • Do you have, or have you had, cellulitis? (ILC)
  • Have you ever had gout? (LC, ILC)
  • Do you get blurred vision? (UC) (ILC)
  • Do you have mucus in your eyes when you wake up in the morning? (UC) (ILC)
  • Do you snore? (UC) (ILC)
  • Do you have sleep apnea? (UC, ALM) (ILC)
  • Have you had your tonsils out? (ILC)

  • Kidneys and Bladder

  • Have you ever had a urinary tract infection (UTI's)? (KB)
  • Have you ever had "burning" upon urination? (KY,ILC)
  • Do you have problems holding your bladder? (parathyroid)
  • Have you ever had kidney stones? (ILC)
  • Do you have bags under your eyes (esp. in the morning)? (KY)
  • Is your urine flow restricted? (KY, ILC)
  • Do you get cramping or pain on either side of your mid-to-lower back? (KY, ILC)
  • Do you or did you ever have nephritis (inflammation)? (KY) (ILC)
  • Do you have or have you had sciatica? (KY, ILC)
  • Do you have lower back weakness? (KY)
  • Do you or did you ever have cystitis (bladder inflammation? (ILC,, KB)

  • Lungs

  • Do you get or have (or have had) any of the following?: (ILC)
  • Are you on inhalers or nebulizers?
  • Do you get pain when you breathe? (ILC)
  • Is it difficult to take a deep breath? (ALM,ALC)
  • Did you ever or do you have lung cancer?
  • Do you have a collapsed lung?
  • Are you a smoker?
  • Have you ever had pneumonia? (ILC,ALC)
  • Have you ever worked around toxic chemicals, in coal mines, or around asbestos? (ET)
  • Do you cough a lot?
  • Do ou get any mucus when you cough?
  • What color is the mucus?

  • Environmental Toxins

  • Have you been vaccinated? (ET)
  • Have you had shots for traveling to foreign countries? (ET)
  • Have you had Flu shots? (ET)
  • Do you have mercury amalgams? (ET)
  • Do you find it difficult to take deep breaths? (ET) (ILC, ALM)
  • Have you been exposed to any of the following: (ET)
  • Have you had radiation or chemotherapy? (ET)

  • Chemical Medications

    List any medications you are currently taking

  • Genetic/Family Medical History

  • You are almost done!!

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