Questionnaire

Your Name (required)

Your date of birth

Your Physician's Name (required)

How did you hear about us?
My physicianFamily member, spouse, friendWebOther

Approximate month and year of last submitted saliva kit sample:
---Not ApplicableJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---Not Applicable201920182017

Are you currently taking antibiotics?
YesNoNo response

Have you completed antibiotics in the last six months?
YesNoNo response

Are you currently taking antidepressant medication?
YesNoNo response

Current health concerns (we understand that this is not an exhaustive list, and that it does not specify severity; please choose all that apply):
InsomniaFatigueMigraineDepressionAnxietyBrain FogRunny NoseChronic Pain

Diagnosed by a physician with any of the following in the last year, even if resolved currently (please choose all that apply):
Pre-diabetesDiabetesCancerThyroid disorderHeart DiseaseStrokeSleep ApneaArthritisCeliac DiseaseFood AllergiesSjögren's syndromeAutoimmune disorder(s) not listed here

Lab confirmation of any of the following (please choose all that apply):
AnaplasmosisBabesiaBartonellaBorreliosisErlichiaMycoplasmaRickettsia

Current oral symptoms/conditions (please choose all that apply):
Root canal(s)Implant(s)Bleeding gumsTooth sensitivityMouth Pain

Used on a daily basis (choose all that apply):
ToothpasteFlossCommercial mouthwashWater flosser with only waterWater flosser with antibacterial rinseOil pullingBaking soda

Do you regularly consume products that contain Stevia and/or Xylitol?
YesNoNo response

Do you restrict or avoid eating refined sugar?
YesNoNo response

Types of oils you cook with (please choose all that apply):
Canola oilCorn oilPeanut oilCoconut oilOlive oil

Are you currently adhering to any of the following diets/ways of eating (please choose all that apply):
KetogenicPaleoBulletproofAtkinsPlant-basedVegetarianVeganFruitarianPescetarianRaw FoodIntermittent fasting

Please list the top five foods you consume most frequently:

Do you have pets?
YesNoNo response

Alcohol consumption:
NeverOccasionallyWeeklyDailyNo response

Cigarette use:
YesNoUsed to, but not anymoreNo response

Have you used an IUD, implant, or oral method of contraception in the last 5 years?
YesNoNo response

Do you currently use an asthma inhaler?
YesNoNo response

Do you regularly use acetaminophen (Tylenol, Paracetamol)?
YesNoNo response

Please list the names of herbs and supplements you are taking or have taken regularly in the last 6 months:

Please add additional herbs/supplements in the "Additional Comments" section below

Your average stress level on a daily basis, apart from major life events:
0 = no stress, 10 = extreme stress. We understand that this is a subjective measurement.
012345678910

Additional comments regarding any of the questions above:

I acknowledge that I am voluntarily providing the above information to Digital Bio Imaging for internal research purposes.