Health Questionnaire

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.
Date
Full Name

First NameLast Name
Height
Weight
Age
Female-Male

FemaleMale
Birth Date

MonthDayYear
Eye Color
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number

Area CodePhone Number
Skype Screen Name
Family Physician and Phone #
Vitals
Blood Pressure (ex: 120/60)

Left SideRight Side
Pulse
Basal Temperature
pH

UrineSaliva
How many bowel movements do you have per day?
What does your diet consist of?
What are your major health concerns or conditions?
Thyroid/Parathyroid (Glandular System)
Do you get cold hands and feet? (TD)

YesNo
Is it easy to put on weight and hard to lose it? (TD)

YesNo
Are your fingernails ridged, brittle or weak? (PD)

RidgedBrittleWeakNone of the above
Do you have varicose or spider veins? (PD)

YesNo
Do you, or have you had hemorrhoids or prolapsed organs? (PD)

HemorrhoidsProlapsed organsNo
Do you get cramping in your muscles? (PD)

YesNo
Is your bladder strong or weak? (PD)

StrongWeak
Do you have an irregular heartbeat? (PD)

YesNo
Do you have Mitral Valve Prolapse (Heart Murmur)? (PD)

YesNo
Do you get headaches or migraines? (PD)(UC)

YesNo
Have you ever had a hernia? (PD)

YesNo
Have you ever had an aneurysm? (PD)

YesNo
Do you have osteoporosis? (PD)

YesNo
Do you have scoliosis? (PD)

YesNo
Do you get irritable easily? (PD) (AL)

YesNo
Do you have low energy levels? (TD) (AL)

YesNo
Do you suffer from symptoms of depression? (PD)

YesNo
Did you score low on your bone density tests? (PD)

YesNoN/A
Do your tests come back showing low Calcium levels? (PD)

YesNo
Do you have, or have you ever had, a goiter? (TD)

YesNo
Do you have spine deterioration, herniated discs, or bone spurs? (PD)

YesNo
Have you been diagnosed with Hashimoto or Reidel disease? Has a family member? (TD)

YesNoFamily member
How much do you sweat? (TD)

LowMediumA lot
Do your legs get tired or cramp after you walk? (PD)

YesNo
Do you bruise easily? (PD)

YesNo
Pancreas
Do you get gas after you eat? (PS)

YesNoOther
Do you feel your foods just sitting in your stomach? (PS)

YesNo
Do you have Acid Reflux? (PS)

YesNo
Do you see any undigested foods in your stools? (PS)

YesNo
Are you thin and have a hard time putting on weight? (PS) (TD)

YesNo
Do your foods pass right through you (diarrhea)? (PS)

YesNo
Do you have moles on your body? (Adrenal & Pancreatic weakness)

YesNo
Adrenal Glands
Medulla (Adrenal)
Are you overweight? (ALM) (TD)

YesNo
Do you have M.S., Parkinson's or Palsy? (ALM)

YesM.S.Parkinson'sPalsyNo
Do you have anxiety attacks, or feel overly anxious? (ALM)

YesNo
Do you feel excessive shyness or inferior to others? (ALM)

YesNo
Do you have tremors, nervous legs, etc.? (ALM)

YesNo
Do you have High or Low Blood Pressure? (ALM)(KY)

HighLowAverage
Blood pressure: ex 120/60
Do you have hypoglycemia (low blood sugar)? (ALM)

YesNo
Do you have Diabetes (high blood sugar)? (ALM)

YesType IType IINo
Do you have tinnitis (ringing in the ears)? (ALM)

YesNo
Do you have shortness of breath or is it hard to take a deep breath? (ALM)

YesNo
Do you have a hard time sleeping or insomnia? (pineal)

YesNo
Do you have Chronic Fatigue Syndrome? (ALM)

YesNo
Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia? (ALM)

YesAddison'sCongenital Adrenal HyperplasiaNo
Do you have heart arrhythmias? (ALM)

YesNo
Cortex (Adrenal)
Do you have elevated blood cholesterol levels? (ALC)

YesNo
Do you have arthritis, bursitis, or any inflammatory issues? (ALC)

YesNoOther
Do you have any "itis' (inflammatory conditions)? (ALC)

YesNo
Explain
Do you have low steroids or cortisol levels? (ALC)

YesNo
Females Only
Are your menstruation's irregular? (pituitary)

YesNo
Do you get excessive bleeding during menstruation?

YesNo
Do you have or have you had ovarian cysts? (ALC)

YesNo
Do you have or have you had fibroids? (ALC)

YesNo
Do you have or have you had endometriosis or A-typical cells? (ALC)

YesNo
Do you have or have you had fibrocystic breasts? (ALC)

YesNo
Do you get sore breasts, especially during menstruation? (ALC)

YesNo
Do you have a low or excessive sex drive?

LowExcessiveAverage
Have you had a hysterectomy?

YesNo
If yes, Date and State if Partial or Full
Did they take any other organs out at the same time? (ie gallbladder)

YesNo
If yes, what other organs?
Have you had a D & C?

YesNo
Have you had a miscarriage?

YesNo
Have you had a difficulty conceiving children?

YesNo
Have you been on Birth Control Pills?

YesNo
If yes, for how long?
Are you currently pregnant?

YesNo
Males Only
Do you have prostatitis (frequent urination esp. at night)? (ALC)

YesNo
If yes, how often do you urinate?
Do you have prostate cancer?

YesNo
If yes, What are your PSA counts?: And Date:
Do you have testicular hypertrophy (enlargement)? (ALC)

YesNo
Do you have a low or excessive sex drive?

LowExcessiveAverage
Do you have erection problems? (ALC) (ALM)

YesNo
Do you have premature ejaculation?

YesNo
Gastro-Intestinal Tract
Do you have gastritis or enteritis? (ALC)

YesNo
Is your tongue coated (white, yellow, green, or brown), especially in the morning?

YesNo
Do you have gastroparesis (paralysis)? (ALM)

YesNo
Do you have a hiatus hernia? (PD)

YesNo
Do you have colitis? (ALC)

YesNo
Do you have diverticulitis? (PD)

YesNo
Do you get or have diarrhea?

YesNo
Do you get or have constipation? (ALM)

YesNo
have you ever had stomach or intestinal ulcers? (PS)

YesNo
Do you or have you had any type of gastro-intestinal cancers? (stomach, colon, rectal, etc.) (ALC)

YesNo
If yes, explain:
Do you have Crohn's Disease? (ALC)

YesNo
Do you have "gas" problems? (PS)

YesNo
Other GI problems:
Liver/Gallbladder/Blood
Do you have a problem digesting fats? (LG)

YesNo
Do fats or dairy foods cause bloating and/or pain in the stomach area? (LG)

YesNo
Are your stools white or very light brown in color? (LG, PS)

YesNo
Do you get pain behind the right, lower rib area? (LG)

YesNo
Do you have "liver" or brown spots on your skin? (not freckles) (LG)

YesNo
Are you jaundiced (yellowing of the skin)? (LG)

YesNo
Do you have any skin pigmentation changes? (LG, ALC)

YesNo
Are you or have you ever been anemic? (SN, AL, LG)

YesNo
Do you have, or have you ever had, hepatitis? (LG)

YesNo
If yes, please indicate A, B, or C:
Heart and Circulation
Do you get chest pains or angina? (ILC, AL)

YesNo
Have you ever had a heart attack (Myocardial Infarction)? (ILC)

YesNo
Have you ever had open-heart surgery?

YesNo
Do you have heart arrhythmia's? (ALM, PD)

YesNo
If so, what kind?
Do you have a heart murmur or Mitral Valve Prolapse? (PD)

YesNo
Do you ever feel pressure on your chest? (ILC)

YesNo
Do you get "prickly" pains anywhere, especially in the heart area? (ILC, ANS)

YesNo
If so, Where?
Do you have, or have you ever had High Blood Pressure? (kidneys)

YesNo
Do you have a Pacemaker or Stints?

YesPacemakerStintsNo
Skin
Do you get or have skin rashes? (ILC)

YesNo
Do you get skin blemishes? (ILC)

YesNo
Do you have Eczema or Dermatitis? (ILC)

YesNo
Do you have Psoriasis? (ILC)

YesNo
Do you itch anywhere? (ILC)

YesNo
If so, where?
Is your skin:

DryOilyCombo
Do you get or have dandruff? (ILC, UC)

YesNo
Do you have skin problems? (ILC)

YesNo
If so, what type:
Lymphatic System
Do you have hair loss or are you bald or going bald? (UC) (ILC)

YesNo
Have you ever had lymph nodes removed? (ILC)

YesNo
Do you have, or have you ever had, a goiter? (TD) (ILC)

YesNo
Do you have any gray hair? (UC) (ILC)

YesNo
Do you have a hard time remembering things? (UC) (ILC)

YesNo
Do you ever get colds or flu-like symptoms? (ILC, UC)

YesNo
Do you have fibromyalgia or scleroderma? (ILC)

YesNo
Do you have sinus problems? (UC) (ILC)

YesNo
Do you have or get sore throats? (UC) (ILC)

YesNo
Do you have swollen lymph nodes? (ILC)

YesNo
Do you have or have you had tumors? (ILC)

YesNo
If so, where?
Type

FattyBenignMalignant
Do you have a low platelet count (blood)? (SP,BM)

YesNo
Is your immune system weak or sluggish? (ILC, SP)

YesNo
Have you had appendicitis or an appendectomy? (ILC)

YesNo
When?
Do you get boils, pimples, cysts, etc.? (ILC)

YesNo
Do you get regular exercise?

YesNo
How many times per week?
Have you ever had abscesses? (ILC)

YesNo
Have you ever had toxemia? (ILC)

YesNo
Do you have, or have you had, cellulitis? (ILC)

YesNo
Have you ever had gout? (LC, ILC)

YesNo
Do you get blurred vision? (UC) (ILC)

YesNo
Do you have mucus in your eyes when you wake up in the morning? (UC) (ILC)

YesNo
Do you snore? (UC) (ILC)

YesNo
Do you have sleep apnea? (UC, ALM) (ILC)

YesNo
Have you had your tonsils out? (ILC)

YesNo
What age?
Kidneys and Bladder
Have you ever had a urinary tract infection (UTI's)? (KB)

YesNo
Have you ever had "burning" upon urination? (KY,ILC)

YesNo
Do you have problems holding your bladder? (parathyroid)

YesNo
Have you ever had kidney stones? (ILC)

YesNo
Do you have bags under your eyes (esp. in the morning)? (KY)

YesNo
Is your urine flow restricted? (KY, ILC)

YesNo
Do you get cramping or pain on either side of your mid-to-lower back? (KY, ILC)

YesNo
Do you or did you ever have nephritis (inflammation)? (KY) (ILC)

YesNo
Do you have or have you had sciatica? (KY, ILC)

YesNo
Do you have lower back weakness? (KY)

YesNo
Do you or did you ever have cystitis (bladder inflammation? (ILC,, KB)

YesNo
Lungs
Do you get or have (or have had) any of the following?: (ILC)

BronchitisEmphysemaAsthmaC.O.P.D.
Are you on inhalers or nebulizers?

YesNo
How often?
What type?
Oxygen saturation level?
Do you get pain when you breathe? (ILC)

YesNo
Is it difficult to take a deep breath? (ALM,ALC)

YesNo
Did you ever or do you have lung cancer?

YesNo
Do you have a collapsed lung?

YesNo
Are you a smoker?

YesNo
If yes, of cigarettes or marijuana?
How much per day?
Have you ever had pneumonia? (ILC,ALC)

YesNo
Have you ever worked around toxic chemicals, in coal mines, or around asbestos? (ET)

YesNo
Do you cough a lot?

YesNo
Do ou get any mucus when you cough?

YesNo
What color is the mucus?

ClearYellowGreenBrownBlack
Environmental Toxins
Have you been vaccinated? (ET)

YesNo
Have you had shots for traveling to foreign countries? (ET)

YesNo
Have you had Flu shots? (ET)

YesNo
Do you have mercury amalgams? (ET)

YesNo
Do you find it difficult to take deep breaths? (ET) (ILC, ALM)

YesNo
Have you been exposed to any of the following: (ET)

Nuclear Wastes or by-productsHeavy MetalsChemicals
If yes to above, please elaborate:
Have you had radiation or chemotherapy? (ET)

RadiationChemotherapyNo, I haven't
If so, how many treatments?
Chemical Medications

List any medications you are currently taking
Medication Names and Reason for taking:
Natural Supplements you are on currently
Allergies
Past Surgeries - major and minor, and the year
Genetic/Family Medical History
Mother
Father
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
Sister(s)
Brother(s)
You are almost done!!
Any other health concerns? (please list anything that was not addressed in this questionnaire):
Option to upload any document you feel is relevant

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Option to attach eye photo. (Right)

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Option to attach eye photo. (Left)

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Thank you!!
I understand that I must join the Ojai Herbal Health Club, a private membership club, so I can legally discuss my health. (cost is $10, refundable on first purchase).*

Yes
Should be Empty:

MARK JAMES GORDON

Health Questionnaire

Vitals

Thyroid/Parathyroid (Glandular System)

Pancreas

Adrenal Glands

Females Only

Males Only

Gastro-Intestinal Tract

Liver/Gallbladder/Blood

Heart and Circulation

Skin

Lymphatic System

Kidneys and Bladder

Lungs

Environmental Toxins

Chemical Medications

Genetic/Family Medical History

You are almost done!!

Thank you!!