Health History Questionnaire
First Name
*
Last Name
*
Email
*
Date of birth
Goal Weight
*
Current Weight
*
Height
*
Occupation
Relationship Status
Single
Engaged
Common Law
Married
Divorced
Widowed
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Number of Children
*
0
1
2
3+
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Have you done Herbal Magic before?
Yes
No
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1. Are you pregnant?
*
Yes
No
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2. Do you have Cystic Fibrosis?
*
Yes
No
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3. Do you have HIV-related complications/AIDS?
*
Yes
No
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4. Do you currently have pancreatitis?
*
Yes
No
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5. Have you given birth in the last six weeks?
*
Yes
No
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6. Have you had a stroke and/or a "mini-stroke" (Transient Ischemic Attack) within the past six months?
*
Yes
No
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7. Do you currently have one of the following serious liver diseases: Cirrhosis, alcohol-induced fatty liver, hepatic encephalopathy?
*
Yes
No
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8. Do you currently have cancer and/or are you undergoing cancer treatment? (Not including maintenance treatments)
*
Yes
No
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9. Do you currently have one the following serious kidney diseases: Chronic Kidney Disease, Chronic Renal Insufficiency, Chronic Renal Failure, Nephrotic Syndrome, dialysis and/or kidney failure?
*
Yes
No
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10. Have you had an organ transplant within the past two years?
*
Yes
No
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11. Have you been diagnosed with alcohol or drug abuse or have you undergone treatment for alcohol or drug abuse within the past 6 months?
*
Yes
No
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12. Do you currently have or have you been diagnosed with an eating disorder (Bullimia, Anorexia Nervosa, Binge Eating Disorder) within the past year?
*
Yes
No
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13. Have you had major organ surgery (e.g. heart, liver, kidneys, lungs, brain, gastrointestinal tract, uterus, pancreas, and/or spleen) within the past 30 days?
*
Yes
No
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14. Do you have or have you had any extensive heart conditions (including congestive heart failure, heart attacks, bypass surgery, pacemaker or stent implantation, and/or pulmonary embolism) within the past six months?
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Yes
No
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15. Have you had any type of surgical weight loss procedure (e.g. gastric bypass, lap-band, etc.) within the past year?
*
Yes
No
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1. Do you have another type of liver disease not mentioned in the previous section Question 7 and not including non-alcoholic fatty liver and Gilbert's Syndrome?
*
Yes
No
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2. Do you have another type of kidney disease not mentioned in the previous section Question 9?
*
Yes
No
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3. Have you had any type of surgical weight loss procedure (e.g. gastric bypass, lap-band, etc.) within the past 2 years?
*
Yes
No
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4. Have you undergone cancer treatment within the past 6 months? (Including maintenance treatment)
*
Yes
No
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5. Are you HIV+?
*
Yes
No
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1. Are you currently breastfeeding?
*
Yes
No
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2. Are you actively trying and/or planning conceive within the next 3 to 6 months?
*
Yes
No
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3. Do you have or have you had any implanted or attached medical devices including but not limited to: pacemakers, orthopedic nails, pins, plates, hip prostheses, knee prostheses, stents, cochlear implants, implanted nerve stimulators, implanted drug administration devices (e.g. insulin pump), implantable defibrillator, aneurysm coils and clips, staples, implanted programmable VP shunts, pregnancy, artificial, heart or lung, kidney dialysis machine, etc.?
*
Yes
No
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4. Do you have Cardiovascular Disease?
*
Yes
No
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5. Do you have high blood pressure?
*
Yes
No
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6. Do you have high cholesterol?
*
Yes
No
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7. Do you have Diabetes?
*
Yes
No
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8. Do you have any other immuno-compromised condition?
*
Yes
No
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9. Do you have iron deficiency?
*
Yes
No
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10. Do you have caffeine sensitivity?
*
Yes
No
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11 A. Do you have any of the following food allergies / intolerance / restrictions? Check all that apply.
*
None / No allergies
Dairy
Gluten
Kosher
Halal
Vegetarian
Vegan
Corn
Soy
Pork
Beef
Fish
Chicken
Shell Fish
Nuts
Other (please list below)
11 B. List any other allergies, intolerances or restrictions:
12. Please list any additional health conditions not mentioned above.
13. How much exercise do you engage in?
*
Lightly active: 10,000 steps daily or less than 3 hours of light activity/week
Moderately active: 3 hours/week of moderate activity or more
Very active: 5 hours minimum/week of very intensive activity (breathless state)
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List all medications that you are currently taking, including prescription drugs, over-the-counter medication, and/or supplements or natural health products. Please include the following details: (i) how long you have taken each and (ii) reason for taking.
The information requested in this questionnaire is necessary for Herbal Magic Corp. to understand your weight loss needs, to determine your eligibility to enroll in our weight loss program and to avoid known contraindicated uses of Herbal Magic products and services. Your personal information will remain confidential and will be handled in accordance with the Herbal Magic Privacy Policy. Please note that your Personal Health Coach is trained to assist and coach you during your weight loss journey but is not a licensed health care professional. For any advice related to a specific health condition or concern, please contact your health care provider. By clicking YES, you acknowledge that all of the above information is complete and accurate to the best of your knowledge.
*
Yes, I agree
No, I do not agree
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