IHH Client Self Assessment - Invictus Health Hub

Client Self Assessment

Please enable JavaScript in your browser to complete this form.

Client Self-Assessment - Step 1 of 13

Personal Information

Name *

First

Last

Gender

Male
Female

Age:

Height: please denote (ft/in) or (cm)

Weight: please denote (kg) or (Lb)

Email *

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Mobile

This is my

First Assessment
Follow-up Assessment

Have you used Cellular Botanicals before?

Your Health Coach may recommend Glandulars to ‘power punch’ certain areas. Do you consent to the use of Glandular medicines in your program?

Vitals Information

(If you are not sure of your vital sign readings you may leave them blank)

Blood Type

Blood Pressure (Right Arm)

Blood Pressure (Left Arm)

Eye Colour

Resting Pulse (bpm)

Basal Temp (Right Armpit) Deg C/F

Basal Temp (Left Armpit) Deg C/F

Urine pH

How Many Times do you move your Bowel Daily? (If not daily, please disclose current frequency)

Do you have Iron dysregulation? *

Answer 'yes' if you have been medically diagnosed with high or low iron, or if you have been instructed to take iron supplements by a medical professional.

Serum Iron (umol/L)

Transferrin (umol/L)

Transferrin Saturation (%)

Serum Ferritin (ug/L)

Do you take Vitamin D supplements Regularly? *

Do you take Vitamin C supplements Regularly? *

What is the brand name & dose?

Please include the brand name, product name & dose in mg.

Please list any pharmaceutical medications you are currently taking, and the intended symptom they have been prescribed to treat. Include any cortisones or anaesthetics used in the past 24 months.

Are you taking any Herbal Products or Supplements? Please list individually below:

WHAT DOES YOUR CURRENT DAILY DIET CONSIST OF?

Please be as honest as possible.

WHAT ARE YOUR PRIMARY HEALTH CONCERNS?

DO YOU HAVE ANY RESIDUAL HEALTH CONCERNS?

PLEASE LIST THESE CONCERNS

The following pages call for vital information to ensure we capture all elements of your current reality; this is crucial in enabling us to build you an effective, all encompassing program. You will only need to check the boxes of the conditions you have, or are currently experiencing. If you have had a particular condition for an extended period of time, check both ‘Past’ & ‘Current’ boxes.

**PLEASE ANSWER THOROUGHLY**

WHAT DO YOU HOPE TO GAIN FROM THIS PROGRAM?

HOW DO YOU INTEND TO PROCEED FROM THIS PROGRAM?

GENETIC/FAMILY HISTORY

Please list all known health concerns for each family member. Leave blank if you aren’t sure.

Mother

Father

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Sibling

Other

PREVIOUS SURGICAL PROCEDURES

Please list all surgical procedures, minor or major, along with the year

THYROID (GLANDULAR SYSTEM)

Do you have Cold Hands or Feet?

Current
Past

Are you Cold, but Burning Inside?

Current
Past

Do you find it Easy to Gain Weight and Hard to Lose It? (Also Adrenals/Cardiovascular)

Current
Past

Do you suffer Headaches / Migraines?

Current
Past

Are you Easily Irritable?

Current
Past

Are you Overweight?

Current
Past

Do you experience low energy or always tired?

Current
Past

Do you have, or have you had any of the following:

Goiter
Hashimoto's
Grave's
Reidel's Disease

The Condition is:

Current
Past

Does a Family Member have, or ever had:

Goiter
Hashimoto's
Grave's
Reidel's Disease

The Condition is:

Current
Past

How Much do You Sweat?

Low
Medium
Excessive

Base your answer on your own perception.

PARATHYROID (GLANDULAR SYSTEM)

Are Your Fingernails: (Check all Applicable)?

Ridged
Brittle
Weak

Do You Have

Varicose Veins
Spider Veins

The Condition is:

Current
Past

Do You Have

Hemorrhoids
Prolapses

The Condition is:

Current
Past

Do you suffer Muscle Cramps / Legs Tiring Easily

Current
Past

Would you Consider Your Bladder

Strong
Leaks a bit
Weak

Do you have, or have you ever had a Hernia

Current
Past

Do you have, or have you ever had an Aneurysm

Current
Past

Have you been Medically/Pathologically Diagnosed with:

Low Bone Density
Low Calcium

The Condition is:

Current
Past

Do You Have

Osteoporosis
Scoliosis
Kyphosis
Lordosis

The Condition is:

Current
Past

Do you Identify with any Mental Health Challenges? (e.g. Depression, PTSD, OCD, etc.) Please List:

The Condition is:

Current
Past

Do You Have

Spinal Deterioration
Herniated Discs
Bone Spurs

The Condition is:

Current
Past

Do you Bruise Easily

Current
Past

PANCREAS

Slow or Sluggish Digestion?

Current
Past

Does Food Pass Through You Quickly (Diarrhoea)?

Current
Past

Do You Experience

Acid Reflux
Heartburn
Indigestion

The Condition is

Current
Past

Do you Notice Undigested Food in Stool?

Current
Past

Do you Consider Yourself Thin, &/or Find Difficulty in Gaining Weight?

Current
Past

Are Moles Present on Your Body (Also Adrenals)

Current
Past

ADRENAL GLANDS (GLANDULAR SYSTEM)

Are you Overweight

Current
Past

Do You Have

MS
ALS
Parkinson’s
Palsy

The Condition is:

Current
Past

Do you Identify with Anxiety?

Current
Past

Do you Experience Excessive Shyness / Inferiority Complex

Current
Past

Do you Experience Tremors / Nervous Legs

Current
Past

Do you Have High Blood Pressure (Also Cardiovascular)

Current
Past

Do you Have Low Blood Pressure?

Current
Past

Do you Have Hypoglycaemia (Low Blood Sugar)

Current
Past

Have you been diagnosed with Diabetes

Current
Past

If Diabetes is Current, please indicate the Type below:

Type 1
Type 2

Do you Experience Tinnitus (Ringing in Ears)

Current
Past

If Tinnitus is Current, Please Indicate Frequency Below:

I notice it SOME of the time.
I notice it ALL of the time.

Do You Have

Difficulty Taking Deep Breath
S.O.B (Short of Breath)

The Condition is:

Current
Past

Do you have any Cardiac Arrythmia : (Also Cardiovascular) Please List Which Type:

The Condition is:

Current
Past

SLEEP: Do you Have any Challenges Getting to Sleep (Also Pineal)

Current
Past

SLEEP: Do you Have any Challenges Staying Asleep (Also Pituitary)

Current
Past

Do You Have

Addison’s Disease
Congenital Adrenal Hyperplasia Current

The Condition is:

Current
Past

Have you been Diagnosed with High Cholesterol?

Current
Past

Do You Have any “Itis” Condition (Arthritis, Osteoarthritis, Bursitis, etc) Please List:

The Condition is:

Current
Past

Have you been Diagnosed with Low Steroids / Low Cortisol

Current
Past

Do You Have

ADD
ADHD
Autism

The Condition is:

Current
Past

FEMALES ONLY

Are You Currently Pregnant?

Are You Currently Breastfeeding?

Irregular Menses (Also Pituitary)

Current
Past

Excessive Bleeding During Menstruation

Current
Past

Reproductive System: Do You Have

Ovarian Cysts
Fibroids

The Condition is:

Current
Past

Reproductive System: Do You Have

Endometriosis
Atypical Cells

The Condition is:

Current
Past

Do you Have Fibrocystic Breasts

Current
Past

Sore or Painful Breasts, Especially During Menstruation

Current
Past

Would you Consider your Sex Drive:

Low
Excessive

The Condition is:

Current
Past

Have You Had a:

Complete Hysterectomy
Partial Hysterectomy

If YES, Were Any Other Organs or Lymph Nodes Removed? Please List Which:

Have you Experienced Difficulty Conceiving?

Current
Past

Are you Currently Utilising a form of Birth Control?

What form of Birth Control are you Using, and for how long has it been utilised?

If Birth Control was Utilised in the Past, please detail what was used, for how long, and the time lapsed since ceasing:

Are there any other issues to report?

MALES ONLY

Do You Have Prostatitis?

Current
Past

How Often do You Urinate?

Have You Been Diagnosed with Prostate ‘Cancer’?

Current
Past

What are your most recent PSA levels?

Please indicate the PSA level and approximate month/year the levels were checked.

Have you experienced Testicular Hypertrophy (Enlarged Testicles)

Current
Past

Would you Consider your Sex Drive:

Low
Excessive

The Condition is:

Current
Past

Do you have Erection Problems?

Current
Past

Do you Experience Premature Ejaculation?

Current
Past

Are there any other issues to report?

GASTRO-INTESTINAL TRACT

Bowel Movements:

Less Than 1 Every 3-4 Days
1 Every Other Day
1-2 Per Day
4+ Per Day

Are your Bowel Movements (tick all that apply):

Explosive
Loose
Formed & Soft
Formed & Cracked
Uncomfortable Nuggets

Do Your Bowel Movements Leave you Feeling:

Satisfied
Unsure about the Effectiveness
Screaming for an Encore

Do You Have

Crohn’s
Colitis
Gastritis
Enteritis
Diverticulitis

The Condition is:

Current
Past

Do you Have Gastroparesis (Paralysis of the Stomach)

Current
Past

Do you Have a Hiatus Hernia?

Current
Past

Do you Have a Coated Tongue, Especially Upon Waking: (white, yellow, green, brown)

The Condition is

Current
Past

Do You Have

Diarrhea
Constipation

The Condition is:

Current
Past

Do You Have

Stomach Ulcers
Intestinal Ulcers

The Condition is

Current
Past

Do You Have Gastro-Intestinal 'Cancer'?

Current
Past

If Yes, Please Provide the Specific Location of where the ‘Cancer’ is/was:

Do you Have Gas Problems (Also Pancreas)

Current
Past

Do you Have any Other GI Issues Not Listed?

These Conditions Are:

Current
Past

LYMPHATIC SYSTEM

Do You Have

Hair Loss
Balding
Fully Bald (not by choice)

The Condition is:

Current
Past

Have You Ever Had Any Lymph Nodes Removed?

From Which Area of Your Body Were They Removed?

How Many Were Removed?

Do You Have

Swollen Lymph Nodes
Lymphedema

The Condition is

Current
Past

Do you have Edema (fluid retention)

Yes
In the past
No

Please Provide Location(s)

Do You Have

Fibromyalgia
Scleroderma

The Condition is

Current
Past

How Often do you have Cold & Flu-like Symptoms?

Every 12 Weeks or less
Every 6 - 12 Months
I Usually Experience at the Cold Turn of a Season
I seem to ALWAYS have a Cold/Flu
I NEVER Get a Cold/Flu

Do You Have

Reoccurring Sore Throat
Reoccurring Sinus Problems

The Condition is:

Current
Past

Do you Consider Yourself to have Poor Memory or Brain Fog

Current
Past

Is your Vision Blurred

Current
Past

Do you Have Mucus in Your Eyes Upon Waking

Current
Past

Have You Been Diagnosed With ‘Cancer’ ?

Yes
In the past
No

Has it been declared 'in Remission'?

Please Detail Stage & Location

Do you Have Any Other Type of Non-Malignant Mass / Tumor:

Fatty
Benign

Please Indicate the Location of Non-Malignant Mass / Tumor:

Do You Have

AIDS
HIV +

The Condition Is

Current
Past

Low Platelet Count (Also Cardiovascular)

Current
Past

Have you Had or Undergone:

Appendicitis
Appendectomy
Tonsillitis
Tonsillectomy

Date of Appendectomy (Appendix Removed):

Date of Tonsillectomy (Tonsils Removed):

Do You have

Boils
Acne
Cysts
Abscesses

The Condition is

Current
Past

Do you have Gout

Current
Past

Do You Have

Toxemia
Cellulitis

The Condition is:

Current
Past

Sleep Apnea

Current
Past

Do You Snore?

Current
Past

KIDNEYS & BLADDER

Do You Have, or have you had

UTI
Bladder Infection
Cystitis

The Condition is

Current
Past

Burning While Urinating

Current
Past

Do You Have

Weak Bladder
Urinary Incontinence

The Condition is

Current
Past

Restricted Urine Flow

Current
Past

Kidney Stones

Current
Past

Nephritis

Current
Past

Cramping or Pain Mid-to Lower Back on Either Side

Current
Past

Lower Back Weakness (Lack of Strength)

Current
Past

Sciatica

Current
Past

Bags Under Eyes

Current
Past

RESPIRATORY SYSTEM

Do You Have

Bronchitis
Asthma
COPD
Emphysema
Pneumonia

The Condition is

Current
Past

Pain or Difficulty Breathing

Current
Past

Pain or Difficulty Taking Deep Breaths (Also Adrenals)

Current
Past

Collapsed Lung

Right
Left

The Condition is

Current
Past

Frequent Cough

Current
Past

Color of Mucus Expectorated

Clear
Yellow
Green
Brown
Black

Are you Required to use a

Nebulizer
Inhaler

Apparatus use is

Current
Past

If Known, what is Your Oxygen Saturation (or SP02)?

Have You Been Diagnosed With Lung ‘Cancer’?

Current
Past

Do you Smoke?

Current
Past

How many cigarettes per day @ what mg?

ENVIRONMENTAL AND OTHER TOXIC EXPOSURE

Have you had Exposure to

Nuclear Wastes
By-Products of Nuclear wastes
Heavy Metals
Toxic Chemicals

The Exposure is

Current
Past

Exposure to Toxic Substances Such as Asbestos or Coal Mines (Also Respiratory System)

Current
Past

Have You Gone Through Chemotherapy or Radiation?

Current
Past

How Many Treatments of Chemo or Radiation?

Have You Received the “Standard” Vaccinations?

Have You Received Vaccinations for Travelling to Foreign Countries?

Have You Received a Flu Shot?

Have You Received the Covid-19 Vaccine?

What brand & type of Vaccine did you opt for?

Did you experience any physical side effects?

Please explain

Did you experience any mental stressors?

Please explain

Do you use a water filter in your home?

What brand & type of filter is it?

Do you live in an agricultural community?

What products are farmed there?

Have You Ever Used 'Recreational' Drugs? (this information is confidential and used to help you attain optimal health only!)

Current
Past

Please List Any ‘Recreational’ Drugs You Have Used:

Please indicate Frequency