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Supplemental Health Questionnaire
Marian May
2020-10-06T19:06:43+01:00
Supplemental Qs
Q1 TNXB Traits
Hypermobile joints
1=moderate
2=severe
Loose or sagging skin
1=moderate
2=severe
Do other people in your family have joint hypermobility?
1=No
2=Yes
History of endometriosis
1=No
2=Yes
Progressive muscle weakness
1=moderate
2=severe
Reduced sensitivity to vibrations
1=moderate
2=severe
Hiatial Hernia
1=moderate
2=severe
Bruise easily
1=moderate
2=severe
Extremities -hands, feet, limbs- may be discoloured and reflect poor circulation
1=moderate
2=severe
Mitral valve prolapse
1=moderate
2=severe
Heart murmur
1=moderate
2=severe
Heart valve problems
1=moderate
2=severe
Immediate family with heart valve problems
1=One
2=More than one
Bowel disorders
1=moderate
2=severe
Gastroparesis
1=moderate
2=severe
Family history of bowel disorders
1=One
2-Many
Diagnosed with a connective tissue disease
1=moderate
2=severe
Fluid retention - puffy tissues
1=moderate
2=severe
Q2 CYP21A2 Traits
Craving for salt
1=moderate
2=severe
Low blood pressure
1=moderate
2=severe
Increased urination
1=moderate
2=severe
POTS - postural orthostatic tachycardia syndrome
1=moderate
2=severe
Type A personality
1=moderate
2=severe
Poor blood clotting
1=moderate
2=severe
Slow wound healing
1=moderate
2=severe
Excessive body hair - hirsutism
1=moderate
2=severe
Excessive facial hair - hirsutism
1=moderate
2=severe
Increased sex drive
1=moderate
2=severe
History of acne
1=moderate
2=severe
History of ovarian cysts
1=moderate
2=severe
PCOS - polycystic ovarian syndrome
1=moderate
2=severe
Intolerance to progesterone medications
1=moderate
2=severe
Intolerance to estrogen medications
1=moderate
2=severe
Have tested with elevated testosterone
1=moderate
2-severe
Have tested with elevated estrogen
1=moderate
2=severe
Have tested with low cortisol
1=moderate
2=severe
PTSD - post traumatic stress disorder
1=moderate
2=severe
Low tolerance to stress
1=moderate
2=severe
Chronic fatigue
1=moderate
2=severe
Emotional processing difficulties
1=moderate
2=severe
Easily overwhelmed by other people's feelings or energies
1=moderate
2=severe
Can read faces well
1=moderate
2=severe
Itching skin
1=moderate
2=severe
Itchy watery eyes
1=moderate
2=severe
Sneezing attacks
1=moderate
2=severe
Seasonal allergies
1=moderate
2=severe
MCAD - mast cell activation disorder - bursts of histamine
1=moderate
2=severe
Throat tightness
1=moderate
2=severe
Fluid retention - puffy tissues
1=moderate
2=severe
Skin flushes easily
1=moderate
2=severe
Diagnosed with IgE mediated allergies
1=moderate
2=severe
Anaphylactic reactions to something
1=moderate
2=severe
Menstrual disorders - if you are post-menopausal, then answer based on previous history
1=moderate
2=severe
Emotionally sensitive
1=moderate
2=severe
Q3 Complement C4 Traits
Family history of autoimmune disease - any of the following: Lupus, Type 1 diabetes, rheumatoid arthritis, Grave's disease, Hashimoto's thyroiditis, Multiple Sclerosis, Celiac disease, Crohn's disease, Behcet's syndrome, Mixed connective tissue disease, Myasthenia gravis, Ankylosing Spondylitis
1=moderate
2=severe
You have been diagnosed with Lupus
1=moderate
2=severe
You have been diagnosed with MS - Multiple Sclerosis
1=moderate
2=severe
You have been diagnosed with Celiac disease
1=moderate
2=severe
You have been diagnosed with Type 1 diabetes
1=moderate
2=severe
You have been diagnosed with Rheumatoid arthritis
1=moderate
2=severe
You have been diagnosed with Hashimoto's thyroiditis
1=moderate
2=severe
You have been diagnosed with Grave's disease
1=moderate
2=severe
You have been diagnosed with Mixed Connective Tissue disease
1=moderate
2=severe
You have been diagnosed with myasthenia gravis
1=moderate
2=severe
You have been diagnosed with Crohn's disease
1=moderate
2=severe
Poor blood clotting
1=moderate
2=severe
Psoriasis
1=moderate
2=severe
Diagnosed with Bi-polar disorder
1=moderate
2=severe
Diagnosed with schizophrenia
1=moderate
2=severe
History of viral infections
1=moderate
2=severe
History of HIV
1=moderate
2-severe
Someone in your family diagnosed with a psychiatric illness
1=moderate
2=severe
You or someone in your family has been diagnosed with Autism Spectrum Disorders including Asperger's Syndrome
1=moderate
2=severe
Family history of motor neuron disease - ALS, Parkinson's, Palsy, Lateral sclerosis, Paraplegia
1=moderate
2=severe
Dysautonomia
1=moderate
2=severe
Lyme disease - diagnosed
1=moderate
2=severe
Mould sensitivity
1=moderate
2=severe
Q4 Your Details
Name
*
City/Town
*
State/Province
*
Country
*
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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