Health Questionnaire

It is essential to see the driving factors behind feeling unwell. This questionnaire will allow you to see what systems in your body are challenged or compromised at the moment, which may be contributing to your current health concerns.

Please select any symptoms that you experience.
You will receive a copy of your State of Health graph, as will the clinic providing this questionnaire, so that you may discuss your health concerns with a professional.

Your information is kept confidential at all times.


Note: All fields marked with a red asterix * are required fields.
Your Details
Name *
Age *
Email *
Phone (if wanting to be contacted by the Clinic)
Diagnosed Medical Conditions (if applicable)
Do you currently take medication for any diagnosed medical conditions?
What is your first concern when it comes to your health? *
Please list what allergies you have:
Please list diagnosed autoimmune diseases:
  • Section One

    This marker reflects imbalances that may be occurring with your hormones or hormonal pathways. Hormones are the chemical messengers of the body, allowing regulation of sleep, appetite, mood, metabolism and hormonal changes in both men and women. This system is closely linked with the "Stress" system, as stress can override the body's natural regulatory mechanisms. The "Liver" system also works hard to metabolise and clear out hormones; so a sluggish liver, as well as medications, can affect this system.

  • Section Two

    This marker reflects the strength of your immune system. The immune system is responsible for fighting viruses, bacteria, parasites and other harmful organisms that find their way into the body. The immune system is constantly fluctuating in order to do its job. Infection occurs if the immune system is weak, tired or the pathogen is too strong. Antibiotic and some medications may affect the strength of the immune system. For some people, the immune system creates inflammatory responses to food and/or environmental substances which results in broad symptoms of hypersensitivity, from skin rashes to fatigue to poor concentration. To help your immune system, stay hydrated, sleep well, and get your daily dose of vitamin D.

  • Section Three

    This marker gives an idea of levels of inflammation your body has been exposed to through dietary and lifestyle choices, medication and illness. This area reflects imbalances that may be affecting the liver, clearance pathways and gut health.

  • Section Four

    This marker reflects your gut health, from entry to exit. Common problems with the gut include indigestion, bloating, pain, Irritable bowel syndrome and candida overgrowth. Your dietary choices, food intolerances, levels of stress and immune system all affect your gut. If the gut is compromised in any way, so is your ability to break down and absorb nutrients; the very foundation of good health. The immune system, mental health and gut are intrinsically linked, so it's not uncommon to see one affect the other.

  • Section Five

    This marker reflects the level of physical, emotional and mental stress in your life, and how much weight this may be having on your symptoms and other major systems. It is most important that stress is addressed, as the body will continually adapt to outside stress, and if we push too hard, much more complex problems have the opportunity to develop.

  • Section Six

    Ancient Chinese Philosophy says the liver is the "seat of anger", where anger, jealousy and hatred are stored. The liver is the body's processing centre; hormones and other chemicals are metabolised by the liver, and it even cycles one of the most important antioxidants in the body, glutathione. The liver activates chemicals and clears out waste. Over time, it can become sluggish and tired. Methylation can also be an issue for some people. Alcohol, medications and a diet rich in processed foods, sugars or carbohydrates stresses the liver and may result in poor function or even damage, such as fatty liver disease. This marker reflects factors that may affect your liver function.


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