HOP - Preliminary Questionnaire - Health Optimization - CMIE

Step 1 of 4 – Informations personnelles

Personal Information

Name:(Required)

First name:(Required)

Date of birth(Required)

MM slash DD slash YYYY

Email address(Required)

Personal medical history

Have you ever suffered from or are you currently suffering from physical illnesses?(Required)

Cardiovascular disease (angina, heart attack, stroke, heart attack, bypass surgery, intermittent claudication…)

Hypertension (high blood pressure)

Diabetes, prediabetes, insulin resistance, gestational diabetes

Polycystic ovary syndrome

Lung diseases (asthma, emphysema, COPD…)

Neurological diseases (neuropathies, multiple sclerosis, migraines, Parkinson’s disease…)

Autoimmune or inflammatory diseases (rheumatoid arthritis, type 1 diabetes, systemic lupus erythematosus, scleroderma…)

Skin diseases (eczema, psoriasis, lichen planus, lichen sclerosus…)

Cancer (please specify the type of cancer, the year of diagnosis, the stage, the treatment(s) received, and whether you are in remission)

Gastrointestinal diseases or problems (gastroesophageal reflux, Crohn’s disease, ulcerative colitis, irritable bowel syndrome…)

Chronic pain (osteoarthritis, lower back pain, nerve pain, shingles…)

Memory problems (Alzheimer’s disease, dementia…)

Gynecological diseases, hormonal imbalance, abnormal bleeding, endometriosis…

Musculoskeletal problems (tendinitis, osteoarthritis, osteoporosis…)

Sleep apnea and hypopnea syndrome. If so, do you use a CPAP to sleep?

Other disease(s) or specifications:

Have you ever suffered from or are you currently suffering from mental health problems?(Required)

Oui

Non

Describe the difficulty or difficulties, the treatment or treatments attempted (medications, therapies…) and the context if applicable, including the year. This includes anxiety, depression, burnout, adjustment disorder, bipolar affective disorder, schizophrenia, toxic or medication-induced psychosis, eating disorders, personality disorders, dependence and/or abuse of alcohol or drugs…(Required)

Have you ever had surgery? Please specify the type of surgery and the year.(Required)

Do you take any medications? Please specify the names and doses.(Required)

Do you take supplements or vitamins? Please specify.(Required)

Family history

What is or was your mother's health like?(Required)

What is or was your father's health like?(Required)

What is or was the health status of your siblings (brothers and sisters)?(Required)

What is the health status of your children?(Required)

Do you have any other family health history in more distant relatives (uncles, aunts, grandparents) that seems relevant to you (multiple cancers, early heart problems, autoimmune diseases, mental health issues, addictions…)?(Required)

Lifestyle habits

Do you smoke or have you ever smoked? If yes, how many cigarettes per day and for how many years?(Required)

Do you consume alcohol: If yes, how many drinks per week on average?(Required)

Consommez-vous du cannabis? Si oui à quelle fréquence?(Required)

Do you use any other drugs? If so, which ones and how often?(Required)

Do you exercise: describe what types of exercise and how often?(Required)

Tell us about your sleep: routines, number of hours, quality, treatments you've tried?(Required)

Tell us about your current diet (omnivorous, carnivorous, vegetarian, vegan, low-carb, ketogenic, carnivore, anti-inflammatory diet…)(Required)

How do you manage your stress (meditation habits, exercise, breathing, time in nature, crafts, applying techniques learned in therapy…)(Required)

What is your current living situation: do you live alone or with someone, are you in a relationship?(Required)

Have you consulted or do you consult healthcare professionals, or have you taken steps in the past or currently to take care of your health, try to treat your problems or symptoms, prevent illnesses, or optimize your health?(Required)

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