HCG Intake Questionnaire Form

HCG Intake Questionnaire Form
All fields are required. The form will not send if they are blank!

First Name A value is required.   Last Name A value is required.
Phone A value is required.      e-mail A value is required.Invalid format.
Address A value is required.     City A value is required.
State A value is required.    Zip A value is required.
Birthday:    Month    Day    Year
SEX:   Male    Female     HEIGHT:
Please make a selection. WEIGHT: A value is required.    Desired Weight: A value is required.

INSTRUCTIONS: Check one of the 4 circles: NA-does not apply , 1-Mild, 2-Moderate, 3-Severe

This intake farm has 3 sets of forms total, Please be aware that it will take a few minutes to fill these forms out in their entirety.

	NA	1	2	3
					Does Not Apply ( selected as shown if the symptom does not apply to you)
					MILD symptoms (once or twice last 6 month)
					MODERATE symptoms (once or twice last month)
					SEVERE symptoms (Chronic, once or twice last wk)

	NA	1	2	3	GROUP 1 SUGAR HANDLING
1					Eat when nervous
2					Excessive appetite
3					Hungry between meals
4					Irritable before meals
5					Get "shaky" if hungry
6					Feeling fatigued, eating relieves
7					"Lightheaded" if meals delayed
8					Heart palpitates if meals missed or delayed
9					Afternoon headaches
10					Upset feeling from excessive eating of sweets
11					Awaken after a few hours sleep, hard to get back to sleep
12					Crave candy or coffee in afternoons
13					Moods of depression, "blues", or melancholy
14					Abnormal craving for sweets or snacks

	NA	1	2	3	GROUP 2 LIVER/BILIARY
15					Dizziness
16					Dry skin
17					Burning feet
18					Blurred vision
19					Itching skin and feet
20					Excessive falling hair
21					Frequent skin rashes
22					Bitter or metallic taste in mouth in the mornings
23					Bowel movements painful or difficult
24					Feelings of worry, dread, or insecurity
25					Feeling queasy; headache over eyes
26					Greasy foods upset
27					Stools light-colored
28					Skin peels on foot soles
29					Pain between shoulder blades
30					Using laxatives
31					Stools alternate from soft to watery
32					History of gallbladder attacks or gall stones
33					Sneezing attacks
34					Dreaming, nightmare-type bad dreams
35					Bad breath (halitosis)
36					Milk products cause distress
37					Sensitive to hot weather
38					Burning or itching anus
39					Crave sweets

	NA	1	2	3	GROUP 3 DIGESTION
40					Loss of taste for meat
41					Lower bowel gas several hours after eating
42					Burning stomach sensations, eating relieves
43					Coated tongue
44					Pass large amounts of foul smelling gas
45					Indigestion 1/2 -1 hour after eating; may be up to 3-4 hrs.
46					Mucus colitis or "irritable bowel"
47					Gas shortly after eating
48					Stomach "bloating" after eating

	NA	1	2	3
					Does Not Apply ( leave it blank or selected as shown if the symptom does not apply to you)
					MILD symptoms (once or twice last 6 month)
					MODERATE symptoms (once or twice last month)
					SEVERE symptoms (Chronic, once or twice last wk)

	NA	1	2	3	GROUP 4A HYPERTHYROID
49					Insomnia
50					Nervousness
51					Can't gain weight
52					Intolerance to heat
53					Highly emotional
54					Flush easily
55					Night sweats
56					Skin is thin and moist
57					Inward trembling
58					Heart palpitates
59					Increased appetite without weight gain
60					Pulse races when resting
61					Eyelids and face twitch
62					Irritable and restless
63					Can't work under pressure

	NA	1	2	3	GROUP 4B HYPOTHYROID
64					Noticeable weight gain
65					Decrease in appetite
66					Easily fatigued
67					Ringing in ears
68					Sleepy during day
69					Sensitive to cold
70					Dry or scaly skin
71					Constipation
72					Mental sluggishness
73					Hair coarse, falls out
74					Headaches upon arising wear off during day
75					Slow pulse, below 65
76					Frequent urination
77					Impaired hearing
78					Reduced initiative

NOTES:

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