Healing Path, Inc.




Health Questionnaire
Are you at Risk?

Assessing unhealthy or premature aging requires careful evaluation of a number of your body's systems. Utilizing this questionnaire, Dr. Donache can focus on those areas of your health that could be at risk for unhealthy aging. Further laboratory testing of those risk areas can identify specific therapies that could help restore you to optimal health.

Once you have completed the questionnaire, Dr. Donache will be in touch via email to set a convenient time by phone to discuss wellness strategies with you. It does not obligate you to further services.

Chronic Inflammation

Do you have elevated cholesterol or triglycerides?

Yes
No

Do you have numbness or tingling in your arms or legs?

Yes
No

Do you eat meat, commercial baked goods, fried foods, or use vegetable oil daily?

Yes
No

Do you consume fish less than 2 times per week?

Yes
No

Do you have high blood pressure, asthma, or colitis?

Yes
No

Do you smoke?

Yes
No

Do you have gingivitis, periodontal disease or not have regular dental cleanings and check-ups?

Yes
No

Poor Nutrition and Digestion

Do you regularly include fast food in your diet?

Yes
No

Do you experience belching, bloating or persistent fullness soon after eating, or do you experience excess flatulence?

Yes
No

Do you experience heartburn or acid reflux?

Yes
No

Have you noticed reactions to specific foods?

Yes
No

Are you fatigued after eating?

Yes
No

Do you have bad breath or a bad taste in your mouth?

Yes
No

Do you use digestive aids (enzymes, ox bile, HCl, etc.), or do you use antacids or acid blocking drugs?

Yes
No

Dysglycemia

Is your waist larger than your hips or are you overweight?

Yes
No

Do you become tired, light-headed, weak, or feel you need to eat 2-3 hours after a meal?

Yes
No

Do you eat dried beans (e.g., pinto, navy, black, etc.) less than 3 times per week?

Yes
No

Do you exercise less than 3 times per week?

Yes
No

Do you eat 3 or more servings of bread, pasta, candy, sweets, soda pop, or fruit juice mostly every day?

Yes
No

Do you eat fewer than five servings of fresh vegetables and fruits per day?

Yes
No

Do you have high blood triglycerides or hypertension?

Yes
No

Impaired Mitochondrial Function

Are you frequently tired for no reason?

Yes
No

Do you have stiff and sore muscles not due to exercise?

Yes
No

Do you have poor stamina, experience shortness of breath, or are you exhausted after exercise?

Yes
No

Do you exercise less than 2 hours per week?

Yes
No

Have you ever been diagnosed as having low iron, or do you have heavy menses?

Yes
No

Do you "look old" for your age?

Yes
No

Have you been exposed to toxic chemicals or heavy metals?

Yes
No

Impaired Detoxification Capacity

Do you become physically ill when exposed to strong smell (perfume, auto-exhaust, etc.) or cigarette smoke?

Yes
No

Do you use chemical solvents at work or in hobbies?

Yes
No

Do you live in a house/apartment or work in a building that is less than 5 years old?

Yes
No

Do you have more than 3 amalgam (mercury) dental fillings?

Yes
No

Are you prone to side-effects from medications or supplements, or have you become more sensitive to the effects of alcohol or caffeine?

Yes
No

Do you have a bowel movement less often than every day?

Yes
No

Do you smoke?

Yes
No

Imbalanced Methylation Reactions

Are you depressed, or have you been treated with drugs for depression?

Yes
No

Do you have joint pains that become worse with use or overuse, or have you been diagnosed with osteoarthritis?

Yes
No

Do you eat fresh leafy greens, spinach, or other green vegetable less than 5 times per week?

Yes
No

Are you a strict vegetarian (vegan - no animal products)?

Yes
No

Have you ever been diagnosed with heart disease or circulatory problems?

Yes
No

Do you experience problems with numbness and tingling in your legs or arms?

Yes
No

Do you experience problems with numbness and tingling in your legs and arms?

Yes
No

Poor Immune Function

Do you catch colds or the flu easily?

Yes
No

Do colds, flu, or other infections tend to linger a long time?

Yes
No

Do you have chronic cough, scratchy throat, sinus congestion, or excess mucous production (must frequently clear your throat)?

Yes
No

Do you have seasonal allergies, or known allergies to dust, pets, or mold?

Yes
No

Have you ever been diagnosed with an auto-immune disease?

Yes
No

Do you have dark circles under your eyes?

Yes
No

Do you have difficulty seeing at night, or do you have white spots on your fingernails?

Yes
No

Hormonal Imbalance

Adrenal Imbalance

Do you frequently feel "stressed out", or "can't handle" stress well?

Yes
No

Do you have difficulty falling asleep or sleeping through the night?

Yes
No

Do sudden noises make you jump?

Yes
No

Do you become dizzy or light-headed when standing up "too quickly"?

Yes
No

Do you crave salt or sugar?

Yes
No

Hormonal Imbalance

Thyroid Imbalance

Are you frequently cold, or have cold hands or feet?

Yes
No

Do you have trouble "getting going" in the morning?

Yes
No

Are you sad or depressed, especially in the morning?

Yes
No

Are you unable to lose weight despite a good diet and exercise?

Yes
No

Do you have diffuse hair loss from the head, arms, or legs?

Yes
No

Hormonal Imbalance

Sex Hormone Imbalance

Are you flabby (loss of muscle tone)?

Yes
No

Do you have a low sex drive?

Yes
No

Do you experience headaches or migraines?

Yes
No

Men

Have you experienced erectile dysfunction (impotence)?

Yes
No

Do you have difficulty starting or stopping urine flow?

Yes
No

Women

Do you have vaginal dryness or pain with intercourse?

Yes
No

Do you have unwanted hair growth?

Yes
No



Thank you for completing the questionnaire. To see the results, please click the "See Results" Button.



 

Healing Path, Inc.
Email us with your questions and comments.
Offices in metro Atlanta, Georgia and National Virtual Clinic
770.931.0123