Gallagher Chiropractic
 

Chiropractic & Wellness

732-291-5656
About Us
About Us
Thank you for Submittng your Questionnaire!

For a professional assessment of the results, please contact your doctor to make an appointment.
(* = required field)
The purpose of this questionnaire is to comprehensively evaluate each of your body's organ system over the last six months.

Instructions
Answer the following questions as best you can. If applicable, answers should reflect symptoms or events experienced within the last six months.

Response Meaning Mark When...
A Always or Yes Symptom or Event is persistant
F Frequent Symptom or Event is Frequent or Common
R Not Applicable or No Symptom or Event is Rare or Uncommon
N/A Not Applicable or No or Never Default selection


1 N/A R F A Consume breads / pastas / starches
2 N/A R F A Yeast / Fungal problems
3 N/A R F A Tickle in your throat
4 N/A R F A Cough / spit clear sputum / phlegm
5 N/A R F A Unexplained weight loss
6 N/A R F A Nervousness or irritable
7 N/A R F A Thinning of skin
8 N/A R F A Prostate problems
9 N/A R F A A family history of diabetes
10 N/A R F A A family history of cancer
11 N/A R F A A family history of heart disease
12 N/A R F A Alcohol socially
13 N/A R F A Alcohol use extensivily
14 N/A R F A Do you use street drugs
15 N/A R F A Drink coffee / soda / ice tea
16 N/A R F A Smoke or use tobacco
17 N/A R F A Eat fast food
18 N/A R F A Eat pre processed / packaged foods
19 N/A R F A Consume sweets
20 N/A R F A Use artificial sweetners
21 N/A R F A Drink cow's milk
22 N/A R F A Consume white sugar
23 N/A R F A Consume refined carbs
24 N/A R F A Consume wheat or gluten
25 N/A R F A Consume artificial flavorings
26 N/A R F A Very little exercise
27 N/A R F A Family or financial stressors
28 N/A R F A Rashes
29 N/A R F A Rosacea
30 N/A R F A Itchy or dry skin
31 N/A R F A Oily skin
32 N/A R F A Acne
33 N/A R F A Eczema
34 N/A R F A Psoriasis
35 N/A R F A skin cancer
36 N/A R F A Vertigo / dizziness
37 N/A R F A Light headedness
38 N/A R F A Glaucoma
39 N/A R F A Cataracts
40 N/A R F A Double vision or blurred vision
41 N/A R F A Dry or red eyes
42 N/A R F A Macular degeneration
43 N/A R F A Watery eyes
44 N/A R F A Itchy eyes
45 N/A R F A Pufffy eyes
46 N/A R F A Ear infections
47 N/A R F A Tooth cavities
48 N/A R F A Bad breath
49 N/A R F A Runny nose / sneezing
50 N/A R F A COPD / lung disease
51 N/A R F A emphysema
52 N/A R F A chronic bronchitis
53 N/A R F A Difficulty breathing deeply
54 N/A R F A Acute or chronic coughing
55 N/A R F A Wheezing with breathing
56 N/A R F A Asthma
57 N/A R F A Shortness of breath
58 N/A R F A Pain when taking a breath
59 N/A R F A Difficulty going to sleeping
60 N/A R F A Difficulty staying asleep
61 N/A R F A Hungry all the time
62 N/A R F A Can't lose weight
63 N/A R F A Can't gain weight
64 N/A R F A Slow metabolism
65 N/A R F A Overweight
66 N/A R F A Gout
67 N/A R F A Diabetes
68 N/A R F A Metabolic syndrome
69 N/A R F A Thyroid problems
70 N/A R F A Too much stress / tension
71 N/A R F A Heat / cold intolerance
72 N/A R F A Cough / spit green-yellowish sputum / phlegm
73 N/A R F A Trouble with edema / swelling
74 N/A R F A Early aging
75 N/A R F A Trouble sweating
76 N/A R F A Fatigued or tired
77 N/A R F A Unexplained swellings
78 N/A R F A Diabetic medications
79 N/A R F A Thyroid medication
80 N/A R F A Diuretics
81 N/A R F A Erectile dysfunction
82 N/A R F A Pre-menopausal
83 N/A R F A Peri-menopausal
84 N/A R F A Suffer from PMS
85 N/A R
Thank you for Submittng your Questionnaire!

For a professional assessment of the results, please contact your doctor to make an appointment.
(* = required field)
The purpose of this questionnaire is to comprehensively evaluate each of your body's organ system over the last six months.

Instructions
Answer the following questions as best you can. If applicable, answers should reflect symptoms or events experienced within the last six months.

Response Meaning Mark When...
A Always or Yes Symptom or Event is persistant
F Frequent Symptom or Event is Frequent or Common
R Not Applicable or No Symptom or Event is Rare or Uncommon
N/A Not Applicable or No or Never Default selection


1 N/A R F A Consume breads / pastas / starches
2 N/A R F A Yeast / Fungal problems
3 N/A R F A Tickle in your throat
4 N/A R F A Cough / spit clear sputum / phlegm
5 N/A R F A Unexplained weight loss
6 N/A R F A Nervousness or irritable
7 N/A R F A Thinning of skin
8 N/A R F A Prostate problems
9 N/A R F A A family history of diabetes
10 N/A R F A A family history of cancer
11 N/A R F A A family history of heart disease
12 N/A R F A Alcohol socially
13 N/A R F A Alcohol use extensivily
14 N/A R F A Do you use street drugs
15 N/A R F A Drink coffee / soda / ice tea
16 N/A R F A Smoke or use tobacco
17 N/A R F A Eat fast food
18 N/A R F A Eat pre processed / packaged foods
19 N/A R F A Consume sweets
20 N/A R F A Use artificial sweetners
21 N/A R F A Drink cow's milk
22 N/A R F A Consume white sugar
23 N/A R F A Consume refined carbs
24 N/A R F A Consume wheat or gluten
25 N/A R F A Consume artificial flavorings
26 N/A R F A Very little exercise
27 N/A R F A Family or financial stressors
28 N/A R F A Rashes
29 N/A R F A Rosacea
30 N/A R F A Itchy or dry skin
31 N/A R F A Oily skin
32 N/A R F A Acne
33 N/A R F A Eczema
34 N/A R F A Psoriasis
35 N/A R F A skin cancer
36 N/A R F A Vertigo / dizziness
37 N/A R F A Light headedness
38 N/A R F A Glaucoma
39 N/A R F A Cataracts
40 N/A R F A Double vision or blurred vision
41 N/A R F A Dry or red eyes
42 N/A R F A Macular degeneration
43 N/A R F A Watery eyes
44 N/A R F A Itchy eyes
45 N/A R F A Pufffy eyes
46 N/A R F A Ear infections
47 N/A R F A Tooth cavities
48 N/A R F A Bad breath
49 N/A R F A Runny nose / sneezing
50 N/A R F A COPD / lung disease
51 N/A R F A emphysema
52 N/A R F A chronic bronchitis
53 N/A R F A Difficulty breathing deeply
54 N/A R F A Acute or chronic coughing
55 N/A R F A Wheezing with breathing
56 N/A R F A Asthma
57 N/A R F A Shortness of breath
58 N/A R F A Pain when taking a breath
59 N/A R F A Difficulty going to sleeping
60 N/A R F A Difficulty staying asleep
61 N/A R F A Hungry all the time
62 N/A R F A Can't lose weight
63 N/A R F A Can't gain weight
64 N/A R F A Slow metabolism
65 N/A R F A Overweight
66 N/A R F A Gout
67 N/A R F A Diabetes
68 N/A R F A Metabolic syndrome
69 N/A R F A Thyroid problems
70 N/A R F A Too much stress / tension
71 N/A R F A Heat / cold intolerance
72 N/A R F A Cough / spit green-yellowish sputum / phlegm
73 N/A R F A Trouble with edema / swelling
74 N/A R F A Early aging
75 N/A R F A Trouble sweating
76 N/A R F A Fatigued or tired
77 N/A R F A Unexplained swellings
78 N/A R F A Diabetic medications
79 N/A R F A Thyroid medication
80 N/A R F A Diuretics
81 N/A R F A Erectile dysfunction
82 N/A R F A Pre-menopausal
83 N/A R F A Peri-menopausal
84 N/A R F A Suffer from PMS
85