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

Health Questionnaire Are you at Risk?

Chronic Inflammation

Poor Nutrition and Digestion

Dysglycemia

Impaired Mitochondrial Function

Impaired Detoxification Capacity

Imbalanced Methylation Reactions

Poor Immune Function

Hormonal Imbalance

Hormonal Imbalance

Hormonal Imbalance

Health Questionnaire
Are you at Risk?