Hemorrhoid Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastSexMaleFmaleHow often do you have a bowel movement? At least dailyEvery 1-3 daysTwice a weekOnce a weekLess than once a week Is your body consistent in the time of day you have a bowel movement? AlwaysSometimesNeverMust you take a laxative to have a bowel movement? AlwaysSometimesNeverMust you generally strain to complete a bowel movement? AlwaysSometimesOftenCannot pass unless strainingHave you ever completed a full colon cleansing program before? NoYes, over 12 months agoYes, once a year or moreIrritable Bowel Syndrome (IBS) As a stress-related health issue, IBS is one of the most common ailments of the digestive system and can cause considerable discomfort. Suffering with IBS can include diarrhea, constipation, or alternating attacks of one and then the other. IBS has a great deal to do with stress and thinking habits, and how thoughts are transferred and manifest throughout the body. IBS can be managed through a reduction in stress, a change in thinking patterns, and/or a change in the number of trigger foods you eat. NoneMildModerateSevereConstipation Many people if they have a bowel movement once every 2-3 days, then they are constipated. In actuality, a bowel movement should happen at least twice a day, without discomfort or straining. If you do not have this regular schedule, you are moderately to severely constipated. Stool should be soft and light brown in color; floating or slowly sinking and easily broken up when the toilet flushes. NoneMildModerateSevereDiarrhea is loose, watery stools, generally passed more than three times a day. People with diarrhea may pass more than a quart of stool a day. Acute diarrhea is a common problem that usually lasts one or two days and goes away on its own without special treatment. Prolonged diarrhea persisting for more than two days may be a sign of a more serious problem and poses the risk of dehydration. Chronic diarrhea may be a feature of a chronic diseaseNoneMildModerateSevereDiverticulosis, a precursor to Diverticulitis Many people have small pouches in their colons that bulge outward through weak spots, (which can be described as similar to an inner tube that pokes through weak places in a tire). This condition is called diverticulosis. It's estimated that 10 percent of Americans over the age of 40 and nearly 50% of all people over the age of 60 have diverticulosis, When the pouches become infected or inflamed, the condition becomes diverticulitis, and can be painful and even life-threatening if the diverticulam rupture, allowing infection and toxins to ooze into the body cavity and wreak havoc. NoneMildModerateSevereBowel Obstruction A bowel obstruction occurs when a mechanical or functional obstruction of the intestines prevents the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and may become a medical emergency requiring surgery if not cared for properly. NoneMildModerateSevereWeight Gain It's been estimated that an adult can have anywhere between five and 25 pounds of waste in their large intestine at any given time (45 pounds have been found during autopsies). While some of this is normal digestive transit, many pounds of feces can be attached the intestinal wall, causing physical and mental fatigue and general feelings of sluggishness within the body, sometimes contributing to further weight gain due to its effects on self-esteem and feelings of well-being. NoneMildModerateSevereHemorrhoids are enlarged, painful veins in your rectum and can be caused by straining during bowel movements. Internal hemorrhoids generally cannot be seen or felt, unlike external hemorrhoids, which can be seen around the outside of the anus. Changes in dietary and bowel elimination habits can greatly decrease discomfort. NoneMildModerateSevereAnal fissures Constipation, straining and hemorrhoids can cause tiny tears around the outside of the rectum. Pain during bowel movements, rectal bleeding, itching, discharge and swelling are common symptoms. NoneMildModerateSevereGas, Bloating and Flatulence Having gas in a normal part of breaking down foods and people will often have some gas throughout the day. When there is an excessive amount of gas or gas that has a particularly foul, strong odor, it is usually the result of the metabolism of sulfur-containing proteins and amino acids in the intestines, or from bacteria overproduction. Continuous and severe bloating and flatulence can be signs of deeper challenges within the intestines. NoneMildModerateSevereParasite Infection Many people think that parasites are only found in third-world nations, but that is not true. While people in wealthier nations suffer less than poorer counties, parasite infections are often one of the most misdiagnosed conditions, since doctors and patients take this common problem for granted. Symptoms can include smelly stools that get fouler later in the day, diarrhea allergies to many foods, itching around the anus, especially in the evening, considerable weight loss, bloating, cramping, and fever, even coughing and wheezing. NoneMildModerateSevereBlemishes or Acne Acne can be a disorder of a backed up colon, and can be caused simply from a sluggish colon, resulting in bacteria backing up in the body and break through the skin causing an improper balance of the friendly bacteria. The skin is our largest eliminative organ. Acne lesions usually occur on the face, neck, back, chest, and shoulders. Although acne is usually not a serious health threat, it can be a source of significant emotional distress. Severe acne can lead to permanent scarring. NoneMildModerateSevereFatigue The word fatigue is used to describe a range of afflictions, commonly referring to a general state of lethargy. Physiologically, "fatigue" describes the inability to continue functioning at the level of one's normal abilities due to an increased perception of effort. Stress, lack of exercise and poor eating habits can lead to fatigue. NoneMildModerateSevereCandida is naturally occurring yeast that is present in all our bodies and it is supposed to be there in balance with many other microorganisms. The problem begins when several factors in our lifestyle : stress, medication(antibiotics), poor diet can cause the Candida to grow in outstanding numbers and it overtakes all the other healthy microorganisms. Once Candida proliferates in the body it wrecks havoc on the body in many ways and is the instigator of many common maladies, conditions, syndromes and illnesses. NoneMildModerateSevereBad Breath (Halitosis) Severely bad breath can be caused by any number of hygienic or health conditions, including bacterial infections and medications. Some bacteria in your mouth may produce gaseous compounds, causing a smell. Since not all bad breath has to do with your hygiene, it's wise to consult your doctor or dentist to exclude a health condition. NoneMildModerateSevereHow would you rate your normal stress level? MildModerateSevereHow active is your lifestyle? Not very active, mostly sedentary lifestyleSemi-active, at least a littleFairly active on a day-to-day basisExtremely activeHow often do you exercise for at least 20 minutes a day?2-3 times a week3-5 times a weekEvery dayWhat kinds of supplements do you take?NoneMultivitaminsCalcium, iron, etc.Other supplements such as glucosamine,Vit D, MSM, herbs, etc.How many over-the-counter medications and prescriptions do you take? None1-56-10How many glasses of water do you drink each day?10+5-93-41-2NoneHow many cups of coffee or tea do you drink daily? None1-23-45-67-910+How many ounces of alcohol do you drink on a weekly basis? 0-8oz8-16oz16-48oz48-64oz64-144ozHow many grams of fiber do you consume on a daily basis? 30+gr26-30gr11-18gr6-10gr1-5grUnknownHow many fast food meals do you eat per week? 1-23-45-67-910+How many servings of fruits and vegetables do you eat per day? None12-34-56-78+Awareness: How do you feel about your health?Confident and happyOptimisticUnsureFearfulAs you are probably aware, age can have a tendency to affect health but doesn't have to. It's good simply to be aware of what factors can affect your health, including age, gender, etc. Overall Attitude about Your Health: HappyOptimisticUnsureFrustratedAngryFrightenedNameSubmit