| All questions marked with a * are mandatory |
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Contact Details |
| First Name: * Middle Initial: |
| Last Name: *
Email Address: * |
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Demographics |
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Gender Male
Female
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Age |
| Height (specify ft or cm) |
Body Weight(specify kg or lbs) |
| Country: * What is your altitude?
(specify feet or metres) |
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What is your location?
What is your environment?
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Health Information (only answer relevant questions) |
1. Overall How would you rate your health during the past month?
Excellent
Very Good
Good
Fair
Poor
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2. How would you rate your health in general now?
Much better now than before
Somewhat better now
About the same
Somewhat worse now
Much worse now than before
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3. During the past 4 weeks, how difficult have physical health problems (illness or injury) made it for you to do your work or other regular daily activities?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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4. During the past 4 weeks, how difficult have emotional problems (such as feeling depressed or anxious) made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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5. How many times were you seen by a healthcare provider (physician etc) for a medical problem or concern in the last year?
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6. Did you have to spend one or more nights in a hospital as a patient in the last year?
No Yes
If yes please give please give dates and reasons:-
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7. Have you been wounded, injured, assaulted or otherwise hurt in the last year?
No Yes
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7a. If YES, are you still having problems related to this event?
No Yes Unsure
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8. Please indicate if you have experienced any of the following symptoms, if they were very serious, and if you are still bothered by them in the last 4 weeks.
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9a. During your life have you experienced any of the following events? (mark all that apply)
Blast or explosion
No Yes
Vehicular accident/crash (any vehicle including aircraft)
No Yes
Fall
No Yes
Other event (for example, a sports injury to your head. etc)
No Yes
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9b. Did any of the following happen to you, or were you told happened to you, IMMEDIATELY after any of the event(s) you just noted in 9a? (mark all that apply)
Lost consciousness or got 'knocked out'
No Yes
Felt dazed, confused or 'saw stars'
No Yes
Didn't remember the event
No Yes
Had a concussion
No Yes
Had a head injury
No Yes
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9c. Did any of the following problems begin or get worse after the event(s) you noted in question 9a? (mark all that apply)
Memory problems or lapses
No Yes
Balance problems or dizziness
No Yes
Ringing in the ears
No Yes
Sensitivity to bright light
No Yes
Irritability
No Yes
Headaches
No Yes
Sleep problems
No Yes
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9d. In the past week have you had any of the symptoms you indicated in question 9c? (mark all that apply)
Memory problems or lapses
No Yes
Balance problems or dizziness
No Yes
Ringing in the ears
No Yes
Sensitivity to bright light
No Yes
Irritability
No Yes
Headaches
No Yes
Sleep problems
No Yes
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10. Do you have any other concerns about possible exposures or events that you feel may affect your health?
No Yes
Please list your concerns:
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11. Do you have any concerns about your health?
No Yes
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12. Have you ever had an experience that was so frightening, horrible, or upsetting that you have:-
Had nightmares about it, or thought about it when you did not want to?
No Yes
Tried hard not to think about it or went out of your way to avoid situations that remind you of it?
No Yes
Been constantly on guard, watchful, or easily startled?
No Yes
Felt dumb or detached from others, activities, or your surroundings?
No Yes
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13. Over the PAST MONTH, have you been bothered by the following problems?
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14. Alcohol is sometimes incompatible with herbal dietary supplements:-
Have you used alcohol more than you meant to?
No Yes
Have you felt that you wanted to or needed to cut down on your drinking?
No Yes
How often do you have a drink containing alcohol?
NeverMonthly or less2 to 4 times a month2 to 3 times a week4 or more times a month
How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 23 or 45 or 67 to 910 or more
How often do you have six or more drinks on one occasion?
NeverLess than monthlyMonthlyWeeklyDaily
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15. Are you worried about your health because you were exposed to: (Mark all that apply):
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16. Have you been exposed to any chemicals or other hazard (industrial, environmental, etc) that required you to seek immediate medical care?
No Yes
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17. Have you entered or closely inspected any destroyed military vehicles?
No Yes
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18. Do you think you have been exposed to any chemical, biological, or radiological warfare agents during your life?
No Don't know Yes
If yes please give date and location
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19. Please indicate which of the following items you used during military service (if applicable).
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20. Have you received any vaccinations recently (select all that apply)
Smallpox (leaves a scar on the arm)NoYes
Anthrax NoYes
Botulism NoYes
Typhoid NoYes
Meningococcal NoYes
Yellow Fever NoYes
OtherNoYes
Don't know
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21. Were you told to take medicines to prevent malaria?
NoYes
If YES, please indicate which medicines you took and whether you missed any doses. (Mark all that apply)
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22. Would you like to further discuss your health concern(s)?
No
Yes
If Yes do you have the following?
Obesity
Diabetes
High Blood Pressure
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23. Are you currently interested in receiving herbal dietary supplements for a stress, emotional or alcohol concern?
No
Yes
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24. Are you currently interested in receiving herbal dietary supplements for a health concern?
No
Yes
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25. Would you like to order herbal dietary supplements formulated on your health assessment information?
No
Yes
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