Research Request Questionnaire

Details

This is the standard form that is given to people who request research assistance from Health Wyze Media. If we have already provided an adequate answer to your problem in one of our articles, or we see an indication that you did not even bother to look, then you will be ignored in either case. You are expected to answer all questions that are relevant to your case, and to do so with absolute honesty. We are more likely to respond if you provide excellent information. Your information will be kept anonymous, We do not help people who attempt to remain anonymous -- as a matter of requiring basic respect. We do not charge for any of our services, but you are welcome to donate at any time. The most important thing to know about us is that we are a Christian organization, which operates under Christian principles. If this makes you uncomfortable in any way, then we would prefer not to help you. Be aware that we take every case very seriously, and we expend great amounts of time in our quest to help good people. However, we are under no obligation to help any particular individual, and we reserve the right to refuse assistance to anyone, for any reason, at will. Disrespect of any kind, or an unwillingness to cooperate with answering our questions usually leads to a termination of communications and future assistance. We are the best at what we do, and we expect to be treated as such.

Fields marked with * are required

Full Name *

Age

Street

City

State/Province

Zip/Postal Code

Country

Telephone

E-mail *

When is the best time to contact you?

How did you find us?

Tell us about you or the patient

What symptoms are you having that led you to come to us? Please be detailed.

How long have you been experiencing the issues that you are contacting us about?

Are you seeking our help due to pressure from a friend or relative?

Did anything noteworthy happen around the time that the problem started, such as a new work environment, a new prescription, etc.?

What drugs are you currently taking (both legally and illegally)? Your secrets are safe with us.

What percentage of your diet consists of processed or restaurant foods?

What percentage of your foods are completely homemade? For example, any recipe that requires store-bought mayonnaise is not homemade.

Do you exercise? If so, please give us a quick summary.

If you had to describe your weight to a doctor, how would you describe it? For example, thin, petite, medium, full-figured, athletic, muscular, chunky, large.

Do you have problems with energy? If so, please elaborate as much as possible. For instance, are you easily exhausted, either mentally or physically?

Have you noticed changes in your skin coloration or eyes?

Do you supplement with non-supplements, such as krill oil or algae products (chlorella and spirulina)?

Do you supplement with any sort of yeast, including brewers yeast and nutritional yeast?

Do you have any food allergies, seasonal allergies, or any other allergies?

Do you eat fermented foods?

Do you experience faintness or low blood pressure?

Are you exposed to any so-called "air fresheners" like Febreze, perfumes, scented dryer sheets, and etc.?

Do you experience nausea and vomiting? If so, when, and how often?

Do you ever crave salt, or salty foods? If so, how often?

Do you experience painful muscles and joints?

Do you routinely use make-up, or other cosmetic products?

Have you had any vaccines within the last two years? List them.

Do you frequently experience irritability, anxiety, or depression?

Is your tongue deep red?

Do you experience dry mouth and cravings for water?

Do you urinate frequently?

Have you experienced any changes in your vision or had vision problems?

Do you use deodorants or antiperspirants? If so, list them.

Where do you get your drinking water? Tell us about it, if it is something other than tap water.

Do you use any diet products, artificial sweeteners, or drink diet drinks?

Are you orally consuming any products containing iodine or iodide, and have you done it in the past?

Do you have irregular or abnormal menstrual cycles?

Do you experience breast soreness outside your menstrual period?

Have you had any surgeries or other medical "help"? List everything.

What vitamins and supplements are you taking?

Do you frequently get sweet cravings?

Have you had any "female problems" or "male problems"?

Describe your typical diet. It's okay to be honest. We're not going to judge you if your diet isn't ideal.

What industry do you work in? Are you consistently exposed to radiation or chemicals in your line of work?

Do you have issues with pain, tingling, or numbness?

What other health problems do you have?

Include anything else that we should know here.

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