Health questionnaire 07092006

JOHN F. COOMBS, B.Sc., M.D.
3 WALTER’S LANE, FALLBROOK, ONTARIO
Mailing address: P.O. Box 20090, Perth, Ontario, K7H 3M6
Telephone: (613) 267-2523 Fax: (613) 267-6216
HEALTH QUESTIONNAIRE
This questionnaire is designed to help you examine some of the many factors affecting your
health. It is long and detailed, but the time spent in answering all the questions is well
worthwhile. Your family history of disease, your past illnesses, your health habits, your home
and work environment all have a direct bearing on your health. PLEASE FILL OUT THIS
QUESTIONNAIRE AS CAREFULLY AS YOU CAN. Many details that seem insignificant
to you may have an important bearing on your diagnosis and treatment. Please add any further
information that might be of help, either in the margins or on a separate piece of paper. The
questionnaire will be kept confidential, and is looked at only by the doctor.
The following information would also be very helpful:
— A short written description of your main medical problems, and what help you would
like from Dr. Coombs.
— A list of treatments that you have undertaken in the past, both conventional and
alternative, and their effect on your condition.
— A complete list of your medications, both past and present, both drugs and nutritional
supplements.
— Copies of previous medical reports and laboratory tests, especially if you have been
under the care of a specialist. [If these are not easily obtained by you beforehand, a request can
be sent from this office at the time of your first visit.]

• PLEASE REMEMBER TO BRING THE COMPLETED QUESTIONNAIRE WITH
YOU TO YOUR APPOINTMENT! DO NOT TRY TO SEND IT HERE IN ADVANCE. It
is not worth the risk of having it delayed in the mail.
• Your first appointment has been booked for 50 minutes. THIS TIME IS SET ASIDE
FOR YOU ALONE. Since there are others who are waiting for appointments, PLEASE
GIVE THIS OFFICE AS MUCH NOTICE AS POSSIBLE IF YOU ARE UNABLE TO
ATTEND.
— PLEASE CALL TO CONFIRM YOUR APPOINTMENT A FEW DAYS (MORE THAN
ONE BUSINESS DAY) BEFOREHAND.
• PLEASE DO NOT WEAR PERFUME, AFTER SHAVE, OR OTHER SCENTED
PERSONAL PRODUCTS TO THE APPOINTMENT. SOME PATIENTS WHO COME
TO THIS OFFICE HAVE VERY SERIOUS REACTIONS ON EXPOSURE TO THESE.
YOUR APPOINTMENT HAS BEEN BOOKED FOR:

________________________ at ________________O'clock
(Please find directions below)
JOHN F. COOMBS, B.Sc., M.D.
152 WALTER’S LANE, FALLBROOK, ONTARIO, K0G 1A0
Telephone: (613) 267-2523 Fax: (613) 267-6216
DIRECTIONS TO FALLBOOK, ONTARIO
FROM OTTAWA:
The slow but sure way, via Perth: (This route is preferable when roads are bad in winter.)
Travel Highway #417 west, past the exits for Kanata and Stittsville, taking exit #145 for Highway #7 west. Travel Highway #7 west,
past Carleton Place to Perth. Continue along Highway #7 through Perth, and at the third set of traffic lights, turn right onto provincial
highway #511 north (which begins at highway #7). Travel 7 km. north to Balderson, turn left onto County Road #7, and follow the
directions 'FROM BALDERSON' below.
The shorter way, via Ferguson Falls:
Those travelling from Carleton Place and Ottawa who are confident with back roads can take a shortcut from Highway #7 which will
save about 10 minutes: 12 km. west of the traffic lights on highway #7 at Carleton Place, beside a grey stone church very close to the
road, there is a right turn clearly indicated for Fergusons Falls and Lanark. This is County Road #15 (paved), which winds scenically 6
km to Fergusons Falls (follow the main road all the way). Another 2.8 km. after Ferguson Falls is a fork in the road, with the main
highway turning right towards Lanark, and a smaller paved road heading straight ahead towards Balderson. Take the smaller road
going straight ahead, and wind your way the 9.5 km. to the village of Balderson. At Balderson, there is a stop sign at the point the road
meets Highway #511. Continue straight ahead, across Highway #511, and follow the paved road (County road #7). Continue with the
directions 'FROM BALDERSON' below.
FROM BALDERSON
As you continue west from Balderson along County Road #7, take the first paved road to the right, which is 2.7 km. from Balderson
(directions to Fallbrook are indicated here). Follow the road another 3 km. into the village of Fallbrook. Immediately as you enter the
village, you will cross a tiny river marked the Fall River, and after the bridge you will see two red brick houses on the left side of the
road, one behind the other. Beside these brick houses is a small laneway marked ‘Walter’s Lane’ (the street sign is on the right hand
side of the road).
-Turn left down this gravel laneway about 500 ft., past the second red brick house and small barn, and over a small causeway which
traverses a swamp. Patient parking is on the left as soon as you enter the cleared area in front of the house.
FROM ALMONTE AND POINTS NORTH:
-Take County Road 16 west from Almonte, which begins at the Petro-Canada gas station on Highway #15. Travel through the village
of Middleville to Hopetown
-County Road 16 meets provincial highway #511 at Hopetown at a T-junction: turn left (south) onto highway #511 toward Lanark.
Travel south on Highway #511 to Lanark.
FROM LANARK VILLAGE:
-Travel through Lanark village to the T-junction at the south end of the village.
-Instead of turning left to follow highway #511, turn right (west), and travel across a bridge and up a hill out of town.
-After travelling about 6.5 km., you will come to a bridge crossing the Mississippi River and immediately following, an ascending hill,
with a clearly lit T junction with a paved road on the left.
-Turn left (south) at this T junction; this is the road to Fallbrook
-About one mile along this road you will come into the village of Fallbrook. Travel into the village, down a hill, and at the foot of the
hill you will see on the left side a sign indicating Walter’s Lane. Turn right and travel to the end of this laneway. Winter route: If
roads are bad in winter, you may prefer to follow highway #511 south from Lanark to the village of Balderson, turn right along county
road #7. Then follow the directions 'FROM BALDERSON' above.
FROM KINGSTON:
-Travel on Highway #15 north, through Elgin and Portland, to Lombardy. Turn left onto County Road #1, and travel through Rideau
Ferry to Perth. County Road #1 turns into Gore Street in Perth. Continue on Gore Street, following the highway indicator signs for
Highway #7. You will make a jog to the left on Foster St., then right onto Wilson St. Continue north to the end of Wilson Street, at
Highway #7. Turn left at the lights at Highway #7, then turn right at the next intersection, which is Highway #511 north. Turn left
(west) at Balderson, then follow the directions 'FROM BALDERSON' above.
FROM THE WEST: Take Highway #7 east to the first set of traffic lights at Perth. Turn left onto Highway #511 north, and continue
as in the first paragraph above, 'via Perth'.
· PLEASE PARK IN THE PARKING LOT AT THE FOOT OF THE STAIRWAY. WALK UP THE STAIRS TO THE FRONT DOOR OF
THE HOUSE. IF YOU CANNOT CLIMB STAIRS (10 SHORT STEPS), YOU MAY USE THE UPPER PARKING LOT AND WALK
ACROSS THE LAWN TO THE FRONT DOOR. IF YOU WILL NEED FULL HANDICAPPED ACCESS, PLEASE NOTIFY US IN
ADVANCE SO THAT WE CAN BE PREPARED TO GIVE YOU ASSISTANCE.
· MANY OF OUR PATIENTS ARE VERY SENSITIVE TO PERFUME AND SCENTED PRODUCTS. PLEASE DO NOT WEAR THESE
TO YOUR APPOINTMENT.
NAME___________________________________________________________ DATE OF BIRTH yy / mm / dd 1
ADDRESS __________________________________________ PHONE #: HOME (____)______-___________
______________________________________POSTAL CODE_________ WORK(____)______-___________
OHIP:____________________________ VERSION CODE:_____ Date Questionnaire Completed : yy / mm / dd
PAST MEDICAL HISTORY:
FAMILY HISTORY -Has any blood relative had any of the
following: circle ‘yes’ or ‘no’ -If so, what relationship:
Have you ever had:
Year OPERATIONS:
yes no ______________________
Bleeding tendency yes no ______________________
yes no ______________________
Repeated infections yes no ______________________
Crippling infections yes no ______________________
yes no ______________________
Chronic lung disease yes no ______________________
yes no ______________________
High blood pressure yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
Convulsions or fits yes no ______________________
Migraine headaches yes no ______________________
yes no ______________________
INJURIES:
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
yes no ______________________
DRUG REACTIONS:
yes no ______________________
______________________________________________ Family member: Age if Health problems?
Age of death if deceased.
HOSPITALISATIONS:
X-RAYS & OTHER TESTS:
___________________________________ __ 4. PLEASE LIST ALL YOUR MEDICATIONS BELOW OR ON OTHER SIDE OF PAGE.
DESCRIPTION OF CURRENT SYMPTOMS & HEALTH PROBLEMS
HAVE YOU EVER HAD ANY OF THE PROBLEMS DESCRIBED BELOW? Circle ‘Yes’ Or ‘No’, And GIVE DETAILS if ‘Yes’
DIGESTIVE SYSTEM
BOWEL HABITS
Average frequency of bowel movements:________________________ Longest time between bowel movements (e.g., if travelling or not well): ________________________________________ Have you ever travelled in the tropics, or had traveller's diarrhoea? GENITOURINARY
MOUTH/ DENTAL
JOINTS/BONES/MUSCLE
NERVOUS SYSTEM
HEART&LUNGS
HORMONAL
GYNAECOLOGY
Started menstruating at age______ Date of last Pap test_________ Interval between periods:______days duration:_________days Flow: light normal heavy Date of last period___________ Number of pregnancies:_______ Number of miscarriages:_________ USE OF HEALTH PROFESSIONALS
Date of last complete medical exam________________ Problems with vaginal discharge: ___yes ___no ___in past, not now During the past year, how many visits have you made to each of the Describe: Mood changes Weight gain Retain fluid Cravings Abdominal symptoms Tender breasts Fatigue Other: __________ ____ Specialist doctor ______ Other counsellor ____ Hospital emergency ______ Dentist Have you ever used, or would you ever consider using, any of the following "alternative" methods of healing?
(Mark the applicable ones)
__Chiropractor __Massage therapist __Naturopath __Homeopath __Acupuncture__ other (please describe)
NUTRITION AND HEALTH
DIETARY HISTORY
Have your eating habits changed over the past 5 years? (Yes No) If so, describe the changes:
________________________________________________________________________
Are you currently following a special diet? (Yes No) If so, describe what kind of diet:
How many meals per week do you skip? _______meals per week. Which ones? ___breakfast ___lunch ___supper
On the average, how many times per week to you eat the following kinds of foods?
____ “Convenience” foods such as TV dinners, Kraft dinner, instant breakfast, canned dinners (stews, spaghetti, etc.), food mixes
____ At fast food outlets (McDonald’s, Tim Horton’s, Col. Saunders, etc.)
Who prepares most of your meals?____________________________________
How often do you read labels while shopping in order to avoid unhealthy ingredients? _____ Rarely ____ Sometimes _____Often
Indicate your average food selections for each meal:
Breakfast______________________________________________________
Lunch_________________________________________________________
Supper________________________________________________________
Snacks________________________________________________________
USE OF FOOD GROUPS:
PROTEIN FOODS: Circle the ones you use daily; underline the ones you use at least a few times each week:
Red meats/ chicken/turkey & other fowl/Fish/Eggs/ Milk products/ beans & soy products/ seeds & nuts
STARCHES: Circle the ones you use daily; underline the ones you use at least a few times each week:
Whole grain (brown) breads/ White or light brown breads/ potatoes/ white rice/ brown rice/ white pasta/whole grain pasta/ dry breakfast
cereals/cooked breakfast cereals/ corn & corn products
VEGETABLES & FRUIT: Circle the ones you use daily:
Raw vegetables/salads/ starchy vegetables (squash, corn, root vegetables) Fresh fruit/ cooked, canned or dried fruit
SWEETS: Underline the ones you use at least a few times each week:
White or brown sugar/ corn syrup/ molasses/ maple syrup/ honey/ candy
FATS: Underline the ones that you use at least a few times a week:
Fried foods/ butter/ margarine/ cream/ gravies/ lard/ vegetable oil
What kind of vegetable oil do you usually use? ____________________________________
BEVERAGES: Circle the ones you use daily; underline the ones you use at least a few times each week:
Water/ black tea/ green tea/ herbal teas/coffee/ decaffeinated coffee/ colas/ other soft drinks/ diet soft drinks
Have you ever taken vitamins or food supplements? ___Yes ____No. If so, do you feel any better for taking them? ___Yes
PLEASE LIST ON A SEPARATE PIECE OF PAPER A COMPLETE LIST OF ALL NUTRITIONAL SUPPLEMENTS YOU
ARE TAKING REGULARLY, AND INCLUDE THIS WITH THE QUESTIONNAIRE. IF SOME OF THEM ARE A DEFINITE
HELP TO YOU, INDICATE WHICH ONES.
Hidden food sensitivities are a very common factor in chronic illness. Some of the more common ones are listed below. Are there any of
these foods that have given you have bad reaction, mild or severe, either now or in the past (such as indigestion, headache, rashes, swelling,
changes in your mood, wheezing, etc.)? If so, indicate which foods below, and describe briefly the reaction you get:
____ artificial flavourings, colourings, or other food additives
____ milk, or milk products
____old cheeses, or vinegar, or pickled products
____ beer, wine, or alcohol
____ coffee or tea
____ sugar or highly sweetened foods
____ chocolate or cocoa
____ wheat or any other grains (specify)
____ bread (especially when fresh), or other baked goods
____ eggs
____ fish
____ shellfish
____ corn
____ nuts, especially peanuts or peanut products
____ tomatoes, or tomato products
____ oranges or grapefruit
____ any other foods:_____________________
Food cravings can be a sign of hidden food sensitivity. Look at the list of foods above, and decide whether there are any of them which
you crave, or that you would find very difficult to give up eating. If so, list these below:
ENVIRONMENTAL AND TOXIC INFLUENCES ON HEALTH
Environmental effects on health can be very significant. Please indicate whether you have noticed an influence from any of the
following environmental factors. If so, please indicate by underlining the appropriate items, and describe your reaction beside
them. Some of these factors may be significant even if you are not aware of any obvious reaction to them. If you have had in the
past significant exposures to mould, chemicals, or electromagnetic fields, (either at home or work) please also circle these below.
ENVIRONMENTAL FACTOR:
DESCRIBE YOUR REACTION OR SIGNIFICANT EXPOSURE NEXT TO THE FACTORS SELECTED.
(underline the ones you react to)
DUST
House dust
Other kind of dusts (road, wood, etc.)
MOULDS
Damp basements
Old buildings/water damaged buildings
Old barns, Old hay/straw
Air conditioners
Other:
ANIMALS
Dog/cat/horse/ other (describe)
FEATHERS
Feather pillows
Birds
POLLENS
Trees
Grasses
Rag weed
Country air
Other pollens:
SMOKE
Wood smoke
Tobacco smoke
Other smoke:
CHEMICALS
Engine exhaust, traffic
Cleaning solutions
Paint fumes/ refinishing fumes
Pesticide/herbicide sprays
Perfumes/scented products
Newsprint
City air
Indoor air in general
Toxic metals
Swimming pools
Other chemicals:
WEATHER
Hot, muggy weather
Damp or muggy weather
Spring or fall weather
Cold weather
Approaching storms
Change in location
Other climactic effects:
ELECTROMAGNETIC FIELDS
Fluorescent lighting
Computer monitors
High-voltage transmission lines
X-ray or nuclear radiation
Other electromagnetic fields:
DRUGS
Aspirin, or other pain relievers
Antibiotics
Others (please describe)
MORE ON ENVIRONMENT AND HEALTH
1. Have you ever had allergy tests? _____yes _____no If so, what did they show? __________________________
2. Have you ever had allergy injections? _____yes _____no If so, to what? ________________________________
If so, did the allergy injections help you (yes/no), or make your symptoms worse (yes/no)?
3. Approximately when was your home built? ___________
4. What kind(s) of heating system does your home have?___ oil ___natural gas
__electric (forced air) __ electric (baseboard) ___wood ___other:________
5. What kinds of flooring does your home have in the bedrooms? ___Carpet __Wood ___Linoleum __Other
6. Does your home have a damp or musty basement, or visible mould around windows or elsewhere?
___ Yes ___No If yes, please elaborate:
________________________________________________________________________
7. In your home, is there a: smoke detector? carbon monoxide detector? fire extinguisher? first-aid kit?
8. When in a car, how often do you use a safety belt?

USE OF DRUGS AND CHEMICALS
Heaviest use of alcohol in the past? _____drinks per day/week/month
Current use of alcohol? __yes __no. _____drinks per day/week/month
Heaviest use of cigarettes in the past? __yes __no. _____packs per day/week/month
Current use of cigarettes? __yes __no. _____packs per day/week/month
Other forms of tobacco consistently used (now or in the past): ____pipe ____cigar
Past use of marihuana? __yes __no . ____times per day/week/month
Current use of marihuana? __yes __no . ____times per day/week/month
Past use of 'recreational' or 'street' drugs? __yes __no . ____times per day/week/month
Current use of 'recreational' or 'street' drugs? __yes __no . ____times per day/week/month
Use of over-the-counter medications on a regular basis? __yes __no Circle which ones below:
Aspirin-Tylenol-Other pain relievers-Cough/cold remedies-Antihistamines-Laxatives-Other: __________

PHYSICAL ACTIVITY AND HEALTH
1. ON THE AVERAGE, HOW MUCH PHYSICAL EXERCISE YOU GET EACH DAY?
___ None, or very little (less than 1/2 mile walking, or less than ten flights of stairs)
___ Some (1/2 -1 1/2 miles walking or 10-30 flights of stairs or daily activities involving some physical activity such
as: raising young children, scrubbing floors, gardening, or work which involves being on your feet most of the time)
___ Fairly active (over 30 flights of stairs or 1 1/2 -3 miles of walking or daily activities involving fairly active
physical effort such as construction work, farming, moving heavy objects by hand, etc.)
___ Very active (over three miles of walking or daily hard physical labour, etc.)
2. DESCRIBE ANY REGULAR, VIGOROUS PHYSICAL ACTIVITY YOU DO. (Vigorous enough to make
your heart pound, your breathing deep, and bring on sweating: such as: sports, running, heavy manual labour)
ACTIVITY:__________________________________________________________
DONE FOR: ______ minutes/hours, ________times per week
3. WHAT, IF ANY, FACTORS MAKE IT DIFFICULT FOR YOU TO KEEP PHYSICALLY ACTIVE?
___ Current illness or general condition
___ Lack of time to exercise
___ Lack of facilities
___ Other (describe): ____________________________________________________
4. ARE YOU OUT OF BREATH AFTER WALKING UP A FLIGHT OF STAIRS? ___ Yes ___No
5. HOW FAR CAN YOU WALK WITHOUT HAVING TO STOP TO REST?_________________
6. HOW FAR CAN YOU RUN WITHOUT HAVING TO STOP TO REST? ___________________
LOW BLOOD SUGAR QUESTIONNAIRE
Low blood sugar (hypoglycaemia) is a common problem affecting mood and energy, yet it frequently
goes unrecognised.
FOR EACH QUESTION PUT AN 'X' IN THE APPROPRIATE COLUMN ON THE RIGHT→
1. Do you crave sweets or sugar-sweetened foods? 2. How often do you eat sugar-sweetened foods? 3. Did you eat a lot of sweets as a child? 4. How often do you have coffee or tea or cola? 5. You find it difficult to go without sweets? 6. Do you find it difficult to go without coffee or tea? 7. Do you feel better if you eat between meals? 8. If your meals are late, do you feel weak, shaky, sick, irritable or tired? 9. Do get a headache if you do not eat? 10. Do you get ravenously hungry if you do not eat? 11. Do you get sweaty if you go too long without eating? 12. If you get light headed or trembling, does food or sweets make you feel better? 13. If you feel tired does food or sweets make you feel more energetic? 14. Do you use sweets or coffee or tea to make you feel less tired? 15. If you get irritable, does eating make your mood improve? 16. Do you feel tired or sleepy after meals? 17. Do you feel tired or sleepy after a large starchy meal or a lot of sweets? 18. Do you ever wake-up at night hungry? 19. Do you ever fall asleep while sitting still? 20. Does your heart ever pound, or go fast, or skip beats? 21. Do you feel frightened or tearful for little or no reason? 22. Do you feel cranky, irritable, sad or miserable for little or no reason? 23. Do you get upset or worried about little things? TOTAL THE NUMBER OF RESPONSES IN EACH GROUP FOR THE 23
QUESTIONS ABOVE →
SOME ADDITIONAL QUESTIONS:
1. Is there diabetes or low blood sugar in your family? 2. Is there a history of alcoholism in your family? 4. Do you have allergies? (Eczema, hay fever, asthma, etc.) 5. How many cups per day do you have of the following: coffee ____, black tea____, cola____? 6. Who are your closest blood relatives who have (or have had) problems with alcohol, or have been prone to excessive drinking? __ Mother ___ Father __Sister or brother __Others(Describe)______________________ 7. Have you ever had a blood sugar test? ___ Yes If so, what were the results? _____ Normal _____ Abnormal _____ Don't know CANDIDA QUESTIONNAIRE
Yeast overgrowth in the intestinal tract is a common problem affecting mood, energy, and immune function, yet it commonly goes unrecognised. Section A. lists factors in your medical history and section B. suggests symptoms commonly found in individuals with yeast -connected illness. SECTION A: MEDICAL HISTORY- Circle the numbers on the right hand side for those POINT
questions which apply to you. (The last 3 questions apply to women only.)
Have you taken tetracyclines (or other antibiotics) for acne for two months or longer?
Have you, at any time in your life, taken other "broad spectrum" antibiotics for respiratory, urinary or 20
other infections for a period of two months or longer, or in shorter courses 4 or more times in a 1-year
period?
Have you taken prednisone, Decadron, or other cortisone type drugs… For more than two weeks?
Does exposure to perfumes, insecticides, fabric shop odours and other chemicals provoke… Are your symptoms worse on damp, muggy days or in mouldy places? Have you had persistent athlete's foot, "jock itch", or other chronic fungus infections of the skin or
nails? If so, have such infections been……
Have you, at any time in your life, been troubled by persistent vaginal problems or had three or more 25
episodes of vaginitis in one year?
Have you been pregnant……
Have you taken birth control pills…For more than 2 years? ADD POINT SCORES TO GET TOTAL SCORE FOR SECTION A →
SECTION B: MAJOR SYMPTOMS-For each symptom which is present, enter the following score in the SCORE
right hand column: SEVERE or DISABLING -9 points, MODERATE- 6 points, MILD- 3 points
Fatigue, or feeling of being "drained" Feeling "spacey" or "unreal', or " brain fog", or poor memory Persistent vaginal infection or burning or itching (women) Endometriosis (women only: a pelvic disease. If you had it, you would recognise the name.) Prostatitis (men only: infection or inflammation of the prostate) ADD POINT SCORES TO GET TOTAL SCORE FOR SECTION B →
EMOTIONAL AND SOCIAL FACTORS IN HEALTH
Thoughts & emotions are very powerful influences in health and healing, especially with chronic illness. This section of the
questionnaire is designed to help explore some of these areas. Please provide further details to the questions, if you are willing. This
section is not meant to be an invasion of privacy, however, and if there are some questions you prefer not to answer, please do give
them some careful thought, but leave the answer spaces blank.
How well do you and the individuals you live with get along?
___Live alone

Do you feel that your home life is contributing to any of your physical or emotional health problems?
___Yes, definitely

What is your occupation, or regular daily activity? _______________________________________

How well satisfied are you with your work (i.e., your employment, schoolwork, or your regular daily activities)?


How difficult do you find your fellow workers (or classmates) to get along with?
___Not applicable (work alone, retired, unemployed) ___Very difficult
Do you feel that your work (or regular daily activities) is contributing to any of your physical or emotional health problems?
___ Yes, definitely

Do your days give you a feeling of being stressed? ___Rarely

If so, elaborate:
Are there significant events in your past that still weigh upon you emotionally?
__Yes, definitely; they a significant on-going stress ___Yes, but I am handling them well ___ No, nothing significant

If so, elaborate:
How much time you spend each day, on the average, in activities that you find relaxing?
(Such as: reading, listening to music, relaxation exercises, walking, etc.)
How much time? ___Rarely
On the average, how many hours of sleep do you get per night? ________ hours
On the average, how many nights per week do you feel that you do not get enough sleep? ______ nights.
For what reasons? ____________________________________
Do you have a religious faith?
If so, please specify, and describe whether it has been of use to you in dealing with your health problems, or past stresses in
your life:


Do those you live with have a religious faith? ___Yes
If this is different than yours, please describe:
'Wholistic health' includes a person's spiritual nature as well as the physical, and seeks healing of all the relationships that
exist within your life: within you, between you and the people in your life, between yourself and God. This kind of healing
can go on even in the face of serious physical illness that will not go away. If you were to address this aspect of health and
healing, what would be your first step?
This questionnaire examines many things we could be doing for our health. To address them all at once may seem
overwhelming. However, we can work to balance, as sensibly as possible, the various demands, risks, costs and benefits one
faces each day. To achieve good balance in my own life, I need to put more emphasis on….

Source: http://www.drcoombs.ca/wp-content/uploads/2008/04/health-quest-07092006.pdf