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Wondering if inflammation is affecting you? 

Chronic inflammation can show up in many different ways and manifest as dysfunction of the body's systems.  This questionnaire rates your neurologic, endocrine, immune, musculoskeletal, gastrointestinal, and detoxification systems based off of your answers.  It will place you on a spectrum of inflammation and results will be interpreted by a functional medicine provider. If you are uncertain if your symptoms could be the result of chronic inflammation, this questionnaire is for you. 

Inflammation Questionnaire

Birthday

What has recently changed in your health that has prompted you to fill out this questionnaire?

1.Are you forgetful, struggle finding words, have brain fog, have a difficult time concentrating, misplace things, or feel more anxious more than usual?

Multi choice

2. Do you feel more depressed for with no identifiable reason? Do you feel you have lost motivation/interest in the things you used to find joy?

Multi choice

3. Do you experience bloating, gas, diarrhea, constipation, or heartburn after eating?

Multi choice

4.Do you struggle with chronic bad breath despite good oral hygeine?

Multi choice

5. Does your weight fluctuate more than 5 pounds in a day or do you feel like your body is larger on some days and smaller/tighter on other days unrelated to fat loss/gain?

Multi choice

6. Do you have unexplained itching flaking or rashes on your hands or feet?

Multi choice

7. Do you experience pain or tenderness in the upper right abdomen that is unrelated to eating?

Multi choice

8. Do you struggle with cravings for sugar/starchy foods even when you have already eaten or feel full (in between meals and after a big meal)?

Multi choice

8. Do you struggle losing weight despite calorie restriction and exercising?

Multi choice

9. Do you experience cold hands or feet even in a warm environment?

Multi choice

10. Do you experience afternoon fatigue, but get a "second wind" before bed causing you to stay awake?

Multi choice

11. Women: Do you expericene irregular periods, painful or heavy periods or changes to libido?

Men: Have you experienced changes in libido or sexual performance such as erectile dysfunction?

Multi choice

12. Do you experience joint pain that comes and goes, or is unrelated to injury?

Multi choice

13. Do you experience pins and needles or tingling sensation in your hands, feet or in your extremities?

Multi choice

14. Do you or anyone in your family have a history of autoimmune conditions like hashimotos, rheumatoid arthritis, lupus, irritable bowel disease, multiple sclerosis?

Multi choice

15. How comited are you to making changes to diet, and lifestyle to improve your health?

Single choice
I am not ready to commit to myself yet.
Considering, but not sure where to start.
I've already started making changes, but still experiencing symptoms.
Very commited to making changes.

What is your timeline for feeling better?

Please choose...

Do you wish to be contacted by Halo Health and Wellness to discuss your questionnaire results?

Single choice
Yes, I want to get to the root cause of my symptoms.
No, I wish to do nothing at this time.
Enjoying the Nature

"No matter how much it gets abused, the body can restore balance. The first rule is to stop interfering with nature"-Deepak Chopra

Thanks for submitting!

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