Form Canadian Lifestyle Health Care - Free Health Screening

 

 Free Health Screening

 

This Free Health Screening is your place for an expert professional opinion on your health matters.

 

Natural Health Screening Form

We are investigating

Dr. Ouellette's FoodPainConnection

with this Screening.

This free health screening is a professional level screening.

Please Note: The Free Screening is a mini screening. For a much more thorough health and pain assessment, take Dr. Ouellette's Wellness Knowledge Calculator, Web Assessment, the Canadian Holistic Online Consultation at TheQ.ca. Please wait 5 seconds for the landing page to automatically redirect to the registration page at TheQ.ca/register.php.

 

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Optional: Please leave your phone number in the format: 000-000-0000



Please don't guess at these following measurements. If you have not checked them recently then re measure now please.

Measure your waist circumference at the NARROWEST point, and your hip circumference at the LARGEST point.

 

Pain Severity Assessment Scale

Indicate the severity of your major pain, from zero to ten, with ten being the most severe.

My pain severity is about:











 

Food Reaction Test

The FoodPainConnection Screening is now available online at our Modules web page at

Wellness Modules

 

Bowel Transit Time

To calculate your BOWEL TRANSIT TIME, eat a large handful of sunflower seeds with a large meal of the day, but do not chew them very well. You want to leave the cellulose layer around the seed. Mark down the time that you take them. (You can also use corn.)

Now watch your bowel movements and when you see the kernels of sunflower seeds, or corn, mark this time down as well.

Calculate the time interval in hours between those two times and that is your Bowel Transit Time. Write it down somewhere please.

 

Nutritional Supplementation

When it comes to nutritional supplementation there are two things you want to know and health care providers wants to know. First, what are your particular nutrition supplements needs? Second, are there any contraindications to taking the more common nutrition supplements? To get started fill out the following sections of this page. Then go to our Wellness Modules page (link below) and purchase the Antioxidant Needs Screening Module V, and the Nutrition Supplements Contraindications Module XI.

Wellness Modules

 

Record your present vitamin, mineral, and other supplement intake. List all of the vitamins, minerals, and other supplements of all kinds of that you consume. Include the manufacturer’s name. Write this on a piece of paper so you can enter it into the computer, or on the alternative, bring the bag of supplements to your computer, read the labels and enter that data into the proper place on the Pain Assessment page of the  PRLStore.com web site.

Bottle or package label name and Manufacturer     

Amount of Ingredients
List every ingredient in the product please, and we need the amounts.
1.   
2.   
3.   

 

Ten Lifestyle Questions

1. Are you familiar with the Five Pillars of Optimal Health Secrets?
     

2. Do you do something regularly to help your spinal health?
     

3. Do you pay attention EVERY DAY, to healthy eating practices?
     

4. Do you practice some kind of fitness program REGULARLY (3-4 times a week) every week?
     

5. Do you know what a well designed fitness program should entail?
     

6. Do you take alcohol on a daily basis? (Alcohol is a stressor to physiological systems.)
     

7. Do you take recreational drugs? (Drugs are a stressor to physiological systems.)
     

8. Are you overweight?
     

9. Are you on a weight loss diet of some kind?
     

10. Are you happy with your life so far?
     

 

Would you like us to contact you by phone to discuss this Screening?
     


Please leave your phone number in the format: 000-000-0000

Please indicate when we should try to contact you.

 
If you wish to start all over again with your form then please click your Reload Page (Refresh Page) button to delete all your data.