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Health Survey
Take this Health Survey and submit the results to Dr. Jim.
First Name:
Last Name:
Address:
Address:
City:
State:
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone:
Email Address:
Part 1 - Pain & Toxicity Assessment Test
Use the drop down selection to answer Yes or No
If the total number of symptoms is
4 or greater
, it might be due to toxic overload and you need a metabolic detox for pain inflammation and fatigue.
Yes
No
Do you feel tied or fatigued?
Yes
No
Do you experience early morning stiffness?
Yes
No
Do you feel stiff after periods of rest?
Yes
No
Do you feel dizzy, foggy-headed or have trouble concentrating?
Yes
No
Do you experience cracking joints?
Yes
No
Do you experience frequent back pain or headaches?
Yes
No
Do you eat fast, fatty, processed or fried foods?
Yes
No
Do you experience generalized aches and pains in the body?
Yes
No
Do you use coffee, cigarettes, candy or soda to get energy?
Yes
No
Are you sleepy in the afternoon?
Yes
No
Do you bruise easily?
Yes
No
Do you recover slowly from moderate exercise?
Yes
No
Do you have food allergies, or are often exposed to chemicals,
sedatives or stimulants?
Yes
No
Do you take pain relievers to get rid of aches and pains?
Yes
No
Do you have a family history of arthritis or auto-immune disorders?
Total number of symptoms
Part 2 - Bio-Inflammation Symptoms Questionaire
Rate each of the following symptoms based upon your typical health profile:
Point Scale:
0 - Never or almost never have the symptoms
1 - Occassionally has it, effect is not severe
2 - Occassionally has it, effect is severe
3 - Frequently has it, effect is not severe
4 - Frequently has it, effect is severe
If any individual section total is
10 or more
, or the Grand total is
50 or more
, you may benefit from a detoxification program.
1. Digestive
0
1
2
3
4
Nausea or Vomiting
0
1
2
3
4
Diarrhea
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated Feeling
0
1
2
3
4
Belching, passing gas
0
1
2
3
4
Heartburn
Total
2. Emotions
0
1
2
3
4
Mood swings
0
1
2
3
4
Anxiety, fear or nervousness
0
1
2
3
4
Anger, irritability
0
1
2
3
4
Depression
Total
3. Eyes
0
1
2
3
4
Watery, itchy eyes
0
1
2
3
4
Swollen, reddened or sticky eyelids
0
1
2
3
4
Dark circles under eyes
0
1
2
3
4
Blurred/tunnel vision
Total
4. Lungs
0
1
2
3
4
Chest Congestion
0
1
2
3
4
Asthma, bronchitis
0
1
2
3
4
Shortness of breath
0
1
2
3
4
Difficulty breathing
Total
5. Ears
0
1
2
3
4
Itchy ears
0
1
2
3
4
Earaches, ear infection
0
1
2
3
4
Drainage from ear
0
1
2
3
4
Ring in ears, hearing loss
Total
6. Energy/Activity
0
1
2
3
4
Fatigue, sluggishness
0
1
2
3
4
Apathy, sluggishness
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Restlessness
Total
7. Head
0
1
2
3
4
Headaches
0
1
2
3
4
Faintness
0
1
2
3
4
Dizziness
0
1
2
3
4
Insomnia
Total
8. Mind
0
1
2
3
4
Poor memory
0
1
2
3
4
Confusion
0
1
2
3
4
Poor concentration
0
1
2
3
4
Poor coordination
0
1
2
3
4
Difficulty making decisions
0
1
2
3
4
Stuttering, stammering
0
1
2
3
4
Slurred speech
0
1
2
3
4
Learning disabilities
Total
9. Mouth/Throat
0
1
2
3
4
Chronic coughing
0
1
2
3
4
Gagging, need to clear throat
0
1
2
3
4
Sore throat, hoarse
0
1
2
3
4
Swollen or discolored tongue, gums or lips
0
1
2
3
4
Canker sores
Total
10. Skin
0
1
2
3
4
Acne
0
1
2
3
4
Hives, rashes or dry skin
0
1
2
3
4
Hair loss
0
1
2
3
4
Flushing or hot flashes
0
1
2
3
4
Excessive sweating
Total
11. Joint/Muscles
0
1
2
3
4
Pain or aches in joints
0
1
2
3
4
Arthritis
0
1
2
3
4
Stiff, limited movement
0
1
2
3
4
Pain, aches in muscles
0
1
2
3
4
Weakness or tiredness
Total
12. Nose
0
1
2
3
4
Stuffy nose
0
1
2
3
4
Sinus problems
0
1
2
3
4
Hay fever
0
1
2
3
4
Sneezing attacks
0
1
2
3
4
Excessive mucus
Total
13. Heart
0
1
2
3
4
Skipped heartbeats
0
1
2
3
4
Rapid heartbeats
0
1
2
3
4
Chest pain
Total
14. Weight
0
1
2
3
4
Binge eating/drinking
0
1
2
3
4
Craving certain foods
0
1
2
3
4
Excessive weight gain
0
1
2
3
4
Compulsive eating
0
1
2
3
4
Water retention
0
1
2
3
4
Underweight
Total
15. Other
0
1
2
3
4
Frequent illness
0
1
2
3
4
Frequent/urgent urination
0
1
2
3
4
Genital itch, discharge
Total
Grand Total Bio-Inflammation
Baughman Chiropractic Clinic and Nutritional Services
938 St. Clair Way, Greensburg, Pennsylvania 15601
724.836.5408 + Email:
askingdrjim@gmail.com
