check

Macrobiotic Consultation Questionnaire - Con't.

Please complete the rest of the questions as fully as possible. Feel free to skip any you do not wish to answer. For questions that do not apply to you, enter "n/a."

Click below to continue.

Start

Macrobiotic History and General Dietary Habits

Basic Information

Question 2 of 64

Are you already versed in macrobiotics and eating a macrobiotic diet?

If so, for how long?

What was/is the reason for your interest in macrobiotics?

 

Question 3 of 64

Briefly describe you current eating pattern. (We'll go into more detail later.)

What do you generally eat for breakfast, lunch, dinner and snacks? 

Question 4 of 64

What are your favorite foods?

Question 5 of 64

What, if anything, do you binge on?

Medical and Health History

Julie Browne holds all information in strictest confidence and shares with no one.

Since you will not be able to back up and change answers, if something needs changing, just let let Julie know in an email our your consultation session.

Question 7 of 64

What is your current weight and height?

Question 8 of 64

TREATMENTS - Past and Current

(Select all that apply)
A

abortion

B

alternative

C

antibiotics

D

appendectomy

E

hysterectomy

F

chemotherapy

G

hormones

H

pain medications

I

medication for physical health problems

J

radiation

K

surgery

L

tonsillectomy

M

counseling

N

psychological medication

O

vaccinations

P

present/previous macrobiotic counseling

Q

none

Diagnoses and Current Symptoms

Please check all that apply. 

At the end of this section I will ask you to list your five most significant current symptoms. 

Question 10 of 64

FATIGUE

 

 

 

(Select all that apply)
A

low energy

B

Anemic

C

recurring colds

D

fatigue

E

none

Question 11 of 64

PAIN

(Select all that apply)
A

ankle

B

lower back

C

upper back

D

chest

E

joint

F

leg

G

hip

H

headache

I

breast

J

wrist, hands, fingers

K

feet, toes

L

knee

M

TMJ, jaw

N

general pain

O

none

Question 12 of 64

INFECTION & OTHER CONDITIONS

(Select all that apply)
A

lung-general

B

difficult breathing

C

heart-general

D

arrhythmia

E

high blood pressure

F

stroke

G

liver-general

H

kidney-genereal

I

pancreas-general

J

poor sugar metabolism

K

stomach-general

L

indigestion

M

nausea

N

intestine-general

O

constipation

P

diarrhea

Q

intestinal pain

R

colon-general

S

spastic colon

T

spleen-general

U

bladder-general

V

frequent urination

W

gallbladder-general

X

sex organs-general

Y

sexual dysfunction

Z

menstrual cramps

AA

dizziness

AB

sense organs-general

AC

faulty vision

AD

faulty sense of smell

AE

faulty hearing

AF

ear discharge

AG

sinus trouble

AH

tooth or gum problems

AI

skin-general

AJ

itchy skin

AK

rash

AL

muscle-general

AM

muscle spasms

AN

circulation-general

AO

cold hands or feet

AP

numbness

AQ

varicose veins

AR

metabolism-general

AS

overweight

AT

underweight

AU

excessive appetite

AV

ulcer

AW

adema

AX

bleeding

AY

hormone and nervous system

AZ

none

Question 13 of 64

HORMONE AND NERVOUS SYSTEM

(Select all that apply)
A

nervous system malfunction

B

impaired movement

C

hormone disorders

D

Parkinson's disease

E

none

Question 14 of 64

CELL DISEASE

(Select all that apply)
A

malignant tumor

B

leukemia

C

skin cancer

D

brain cancer

E

lung cancer

F

liver cancer

G

benign tumor

H

kidney cancer

I

stomach cancer

J

male reproductive cancer

K

ovarian cancer

L

Hodgkin's disease

M

AIDS

N

herpes

O

viral infection

P

cell disease-general

Q

lymphoma

R

breast cancer

S

bone cancer

T

cancer in remission

U

fungal/yeast infection

V

HIV positive

W

psychological

X

insomnia

Y

disturbed sleep

Z

depression

AA

compulsive

AB

emotional extremes

AC

psychological-general

AD

none

Question 15 of 64

Please list your history of any of the following:

 

Accidents, surgeries, hospitilizations, infections, diseases, chronic or recurrent illnesses.

 

At what age occured. 

 

Incude current events. 

 

 

 

Question 16 of 64

What are your five most significant symptoms?

Question 17 of 64

Please describe what, if any, psychological issues you have found challenging and any treatment you've had. 

Question 18 of 64

Nighttime urination

A

weekly

B

nightly

C

never

Question 19 of 64

Daily urination

A

normal

B

burning

C

painful

Question 20 of 64

Bowel movements

A

daily

B

every other day or every few days

C

weekly

D

other

WOMEN

Please describe any symptoms you may have and answer other questions.

Question 22 of 64

Menstrual cycle length and frequency:

Question 23 of 64

Cycle discomfort (PMS, cramps):

Question 24 of 64

Vaginal discharge:

Question 25 of 64

Birth control method(s) used:

Question 26 of 64

Children's births - number? naturally or medically aided?

MEN

Special quetions

Question 28 of 64

Number of times ejaculate per week?

Question 29 of 64

Do you feel fatigued after ejaculation?

A

Yes

B

No

Question 30 of 64

Birth control used:

Prescriptions and Supplements

Past and Present

Question 32 of 64

PAST prescription and over-the-counter medication/drug use:

What medication and drugs have you taken?

Please list, and include duration (months/years)

Question 33 of 64

PRESENT medication/drug use:

What medication and drugs are you currently taking?

Please list. 

Include name, dosage, frequency of use, reason for use, who prescribed, and duration (months/years).

Question 34 of 64

Please list any recreational drug and/or alcohol use, and frequency.

Question 35 of 64

PRESENT vitamins, minerals and other supplements, including any microdosing of pyschedelics, etc.

Please list. 

Include name, dosage, frequency of use, reason for use, who prescribed, and duration (months/years).

FAMILY

Questions about family health and dynamics

Question 37 of 64

Please describe your parents health:

Question 38 of 64

Please describe your parents relationship with each other:

Question 39 of 64

How would you describe your parents relationship with you in the past and now?

Question 40 of 64

Are there any other significant family dynamics or health history not already mentioned?

Question 41 of 64

Do you have or have you had any addiction issues, either with physical substances or other kinds of addictions? Please describe. Are they current or in the past? 

Question 42 of 64

Are you in a relationship which involves domestic violence? If yes, please describe:

Question 43 of 64

Are you a survivor of any kind of childhood trauma, such as sexual abuse, or physical or emotional abuse or neglect? Or trauma as an adult?

 

If so, what have you done to resolve this/these issues?

 

Do you feel that it is resolved? Please describe:

DIETARY HISTORY

This section will capture as accurate a picture as possible of your dietary practices.

 

Question 45 of 64

Before Macrobiotics:

What foods and snacks do/did you strongly crave?

Question 46 of 64

After macrobiotics:

What foods and snacks do you strongly crave?

(Skip this question if new to macrobiotics. )

FREQUENCY OF CONSUMPTION

Now I will ask you to follow a link and fill out a Google Sheet, then upload it to this questionnaire.

 

Question 48 of 64

Please do the following to comlete the Food Intake Checklist:

 

1. copy and paste this link into your browser:

 

https://docs.google.com/spreadsheets/d/1BCEtcGzMPQgea4Tkt60ryY0Z8zXUyu73AdnilFSOtBg/edit#gid=0

 

2. fill out the checklist

 

3. download completed checklist to your computer as a PDF

 

4. then upload it to this questionnaire

 

 

 

  

file_upload
insert_drive_file

RELATIONSHIP DYNAMICS AND WORK

These questions pinpoint where you get your satisfaction and sources of major stressors.

Question 50 of 64

In which relationship(s) do/es your greatest happiness lie?

Question 51 of 64

What, if any, significant challenges in your family do you have? Please describe:

Question 52 of 64

Do you have any painfully difficult relationships? How does this affect you?

Question 53 of 64

Overall, is your work more of a source of joy, or pain and frustration? Please explain:

Question 54 of 64

What else, if anything, is a major concern for you right now? Please describe:

PERCEPTIONS & DREAMS

Please share your thoughts on these last few questions :)

Question 56 of 64

What is your life motto? (e.g. "Do unto others...", "Live for today...")

Question 57 of 64

What are the main things supporting your health right now?

Question 58 of 64

What are the main things you think are negatively impacting your health right now?

Question 59 of 64

What are the top 3-5 ways your health negatively impacts your current lifestyle, career, and future aspirations?

Question 60 of 64

What do you think caused your current condition(s)- what do you believe to be its/their origin?

Question 61 of 64

What, if anything, do you feel you have done to contribute to your condition(s)?

Question 62 of 64

What do you believe you can do from here forward to change your condition?

Question 63 of 64

Who needs you on your A-game?

What are you striving to do for yourself, your family and your community?

Question 64 of 64

Psychological

A

Insomnia

B

Disturbed sleep

C

Depression

D

Compulsive

E

Emotional extremes

F

Psychosis or delusions

G

Psychological — general - please explain

H

None

Confirm and Submit