35018 dr jaa gen screen quest

Please answer the following questions by X the most appropriate answer 1. Have you been treated with antibiotics? 2. Have you ever had any problems with yeast infections? 3. Do you eat or crave a lot of sweet foods? 4. Do you have a problem with food allergies? 5. Have you suffered from any food poisoning? 6. Do you or have you consumed alcohol on regular basis? 7. Have you ever taken the drugs Tagamet or Zantac? 8. Do you take aspirin, panadeine or other pain killers? 9. Do you take any other types of drugs regularly? 10. Are you often in contact with organic chemicals? (i.e. insecticides, herbicides, petro chemicals etc) 11. Do you react to strong perfumes, car exhaust, etc? 12. Do you or have you ever smoked or used tobacco products? 13. Are you exposed to passive cigarette smoke? 14. Do you consume beverages/food containing caffeine? LIVER DETOXIFICATION TEST (LDT) SCREENING QUESTIONS
A certain percentage of patients will experience adverse reactions during the LTD. The reactions include, butare not limited to: shakiness, headaches, nausea, palpitations, light-headedness and sweating. The followingquestions will help isolate those patients who may experience these types of reactions.
1. Do you react when you consume caffeine-containing beverages or food? 2. Are you sensitive to food additives such as M.S.G.? 3. Do you have a history of liver problems? If yes please describe the type of problem: 4. Are you currently taking any drugs? If yes, list below: DR JAA’S MEDICAL HEALTH
Suite 6, Riverwalk One, 140 Robina Town Centre Drive, Robina Qld 4226 ■ Dr. David Jaa MBBS(UQ), B.Med. Sc.(UQ), GDPM(Syd.U), Master of PM(Syd.U), FACNEM, FACPM(Syd.U)
Phone: (07) 5562 2088 Fax: (07) 5562 2085
Dr. Eugene Jaa MBBS(UQ), DRCOG, FAMAC, Dip Obst.(Auck), MRACGP
Rate each of the following symptoms based upon your health profile for the past 30 days.
This is to assist your Doctor to assess your conditions.
0 = Never or almost never have the symptom1 = Occasionally have it, effect is not severe2 = Occasionally have it, effect is severe3 = Frequently have it, effect is not severe4 = Frequently have it, effect is severeX = Not sure DIGESTIVE
DiarrhoeaConstipationBloated FeelingBelching or passing gasHeart burnIntestinal / Stomach Pain Itchy EarsEar aches, ear infectionsDrainage from earRinging in ears, hearing loss EMOTIONS
Mood SwingsAnxiety, fear or nervousnessAnger, irritability, or aggressivenessDepression ACTIVITY
Apathy, lethargyHyperactivityRestlessness Watery or itchy eyesSwollen, reddened or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision(does not include near or far-sightedness) Irregular or skipped heartbeatRapid or pounding heartbeatChest pain ArthritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tiredness Chest congestionAsthma, bronchitisShortness of breathDifficulty breathing Poor memoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilities Gagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen or discoloured tongue, gum, lipsCanker sores Stuffy noseSinus problemsHay feverSneezing attacksExcessive sweating AcneHives, rashes, or dry skinHair lossFlushing or hot flushesExcessive sweating Binge eating / drinkingCraving certain foodsExcessive weightCompulsive eatingWater retentionUnderweight Frequent illnessFrequent or urgent urinationGenital itch or discharge GRAND TOTAL

Source: https://www.drjaasmedicalhealth.com/pdf/GenScreenQuestP1.pdf

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