Chakaura by Michele

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ChakauraTM Power Your Life!

To Transform, Create and Heal

with Michèle St. Amour

Advanced Health Assessment

Chakaura™ Extended Health Questionnaire

Name(Required)
Please include area code or country code if outside Canada or Mexico.
Address(Required)
What was your sex at birth?(Required)
MM slash DD slash YYYY
What is your marital status?(Required)
Do you work?(Required)

Please note that the information requested below is to help get a better picture of your current state to be able to assess possible side effects, causation of health issues or future ailments.

Are you suffering from any physcial issues or injuries?(Required)
This could range from something minor to a permanent disability within the last 6 months.
Do you have past physical or other injuries? (over the past 6 months)(Required)
Do you have any of the following: Please check all that apply(Required)
If female are you pregnant:
Are you suffering from any emotional or mental difficulties? * For example, addiction, anger, anxiety, burnout, depression, mood swings, self-esteem, stress, racing mind, trauma, etc.(Required)
How is your mood throughout the day?(Required)
When are you MOST productive?(Required)
Have you received any of the following vaccines in the past?(Required)
Flu vaccine, Shingles vaccine, mRNA vaccine (Covid-19) such as Pfizer, Moderna, Johnson & Johnson, AstraZeneca, and Boosters. (Please note that we are not asking you to get additional vaccines or boosters, we want to know what you have received to date to be able to assess possible side effects, if any.)
For example: Blood clots, Chest pains, Chronic lethargy/Fatigue, Depression, Digestion/gastrointestinal, Dizziness, Headaches/migraines, Heart attacks, Joint pains/arthritis/chronic inflammation, Lung issues/pneumonia, Myocarditis/pericarditis, Paralysis/Bell’s Palsy, Shingles, Skin sensitivity/irritations, Strokes, Unfocussed, Unusual fears/thoughts, Vaginal bleeding, miscarriages, etc.

Personal Health Assessment

Rate each of the following symptoms based upon your typical health profile.

Head

Headaches, Migraines(Required)
Faintness; Dizziness(Required)
Insomnia(Required)

Eyes

Watery or Itchy Eyes(Required)
Blurred or Tunnel Vision(Required)
Near or Far-sightedness(Required)
Bags or Dark Circles Under Eyes(Required)
Swollen, Reddened, or Sticky Eyes(Required)

Ears

Itchy Ears(Required)
Earaches or Ear Infections(Required)
Ear Drainage(Required)
Ringing in ears(Required)
Hearing Loss(Required)

Nose

Stuffy Nose(Required)
Hay Fever(Required)
Sinus Problems(Required)
Sneezing Attacks(Required)
Excessive Mucus Formation(Required)

Mouth & Throat

Canker Sores(Required)
Swollen or Discolored Tongue, Gums or Lips(Required)
Chronic Coughing(Required)
Sore Throat(Required)
Gagging or Frequent Throat Clearing(Required)
Hoarseness or Loss of Voice(Required)
Hyperthyroidism(Required)
Hypothyroidism(Required)

Skin

Acne(Required)
Dry Skin(Required)
Eczema(Required)
Excessive Sweating(Required)
Flushing or Hot Flashes(Required)
Hair Loss(Required)
Hives or Rashes(Required)
Psoriasis(Required)

Heart

Chest Pain(Required)
Irregular or Skipped Heartbeat(Required)
Rapid or Pounding Heartbeat(Required)
Heart Disease(Required)
High Blood Pressure(Required)
Low Blood Pressure(Required)
Pacemaker(Required)

Lungs

Asthma(Required)
Bronchitis(Required)
Chest Congestion(Required)
Shortness of Breath(Required)

Digestive Tract

Belching(Required)
Bladder Issues(Required)
Celiac Disease (Gluten Intolerance)(Required)
Colitis(Required)
Constipation(Required)
Diarrhea(Required)
Feeling Bloated(Required)
Heartburn or Acid Reflux(Required)
Intestinal or Stomach Pain(Required)
Kidney Issues or Disease(Required)
Liver Issues or Disease(Required)
Nausea(Required)
Passing Gas(Required)
Vomiting(Required)
Hemorrhoids(Required)

Joints / Muscle / Bones

Ankle Problems(Required)
Arthritis or Rheumatism(Required)
Elbow Problems(Required)
Feeling or Weakness or Tiredness(Required)
Hip Problems(Required)
Jaw Problems(Required)
Knee Problems(Required)
Osteoporosis(Required)
Pain or Aches in Joints(Required)
Pain or Aches in Muscles(Required)
Shoulder Problems(Required)
Stiffness or Movement Limitation(Required)
Prosthesis or Articial Limb(Required)
Wrist Problems(Required)

Weight

Binge Drinking(Required)
Binge Eating or Compulsive Eating(Required)
Excessive Weight(Required)
Lack of Appetite(Required)
Type 1 Diabetes(Required)
Type 2 Diabetes(Required)
Underweight(Required)
Water Retention(Required)

Nervous System

Adult attention-deficit/hyperactivity disorder (ADHD)(Required)
Depression(Required)
Fibromyalgia(Required)
Numbness in Limbs(Required)
Panic Attacks(Required)
Parkinson's Disease(Required)

Energy / Activity

Adrenal Issues(Required)
Apathy or Lethargy(Required)
Chronic Fatigue(Required)
Fatigue or Sluggishness(Required)
Hyperactivity(Required)
Menopause/Andropause(Required)
Restlessness(Required)
Sleep Distrubances(Required)

Mind

Confusion or Poor Comprehension(Required)
Difficulty Making Decisions(Required)
Experience Synchronicities(Required)
Highly Intuitive(Required)
Learning Disabilities(Required)
Poor Concentration(Required)
Poor Memory(Required)
Poor Physical Coordination(Required)
Racing Mind(Required)
Slurred Speech(Required)
Stuttering or Stammering(Required)

Psychological Climate

Agressiveness(Required)
Always Feel Like It Is Your Fault(Required)
Anger or Irritability(Required)
Anxiety or Nervousness(Required)
Fear for Finances, Home, Survival, Job(Required)
Feeling of Isolation(Required)
Irrational Fears(Required)
Mood Swings(Required)
No Time For Yourself(Required)
Poor Self-Esteem(Required)
Things Never Go Your Way(Required)
Thinking About The Past(Required)
Stuttering or Stammering(Required)

Immune System & Other

AIDS(Required)
Cancer(Required)
Frequent Illness(Required)
Genital Itch or Discharge(Required)
Frequent or Urgent Urination(Required)
Herpes Complex(Required)

Lifestyle - A Birds Eye View of Your Life. The Little Things Can Make A Huge Wave.

For example: Computers, Gaming, Phone, Social Media, TV.
What kind of social media or apps do you use?(Required)
Do you engage in watching pornographic type material online or videos?(Required)
It is important to know many people are suffering from hormonal deficiencies due to over-stimulation and exertion of various glands.
If yes, how often do you watch pornographic materials?
For example: Yoga, 3 times a week for an hour.
How many hours of sleep at night are you getting?(Required)
What time do you generally go to bed at night?(Required)
:
What time do you generally wake up in the morning?(Required)
:

Fitness and Nutrition

What are your Fitness and Nutritional Goals?(Required)
Check your 3 most important goals.
What is keeping you from achieving your Fitness and Nutritional Goals?(Required)
Check All That Apply.
Are there any physical limitations that would inhibit or limit your participation in an exercise program?(Required)
Do you take any vitamins, minerals, or supplements?(Required)
Are you a Vegetarian?(Required)
Are you a Vegan?(Required)
Do you eat read meat?(Required)
Indicate how many times you eat daily, per week and per month.
Do you eat chicken?(Required)
Indicate how many times you eat daily, per week and per month.
Do you eat fish?(Required)
Indicate how many times you eat daily, per week and per month.
Do you have a diet / nutritional plan that you follow?(Required)
Do you have cravings for sweets?(Required)
Do you have cravings for salty foods?(Required)
How often do you eat?(Required)
How often do you eat out?(Required)
Do you eat Breakfast?(Required)
Do you have a mid morning snack?(Required)
Do you eat lunch?(Required)
Do you have a mid afternoon snack?(Required)
Do you have dinner?(Required)
Do you have a dessert?(Required)
Do you have an evening snack?(Required)
Do you eat refined processed grains?(Required)
( bread of any type, bagels, pasta, muffins, cakes, pancakes, waffles, etc)

How Often Do You Eat The Following Processed Grains and Dairy Products?

Breads & Buns(Required)
Muffins, Croissants, Bagels(Required)
Pasta(Required)
Cakes & Pies(Required)
Milk(Required)
Yogurt Sweet / Fruit(Required)
Plain Yogurt(Required)
Cheese(Required)
Cottage Cheese(Required)

Drinks

What types of water do you drink? Select all that apply.(Required)
If specialty coffee please describe, Indicate if you add anything to your coffee.
Indicate what type of tea and if you add anything to it.
Tobacco Use(Required)
Marijuana Use(Required)
Alcohol Use(Required)
Recreational Drug Use(Required)
Please be honest.
Please be brief.
Please be brief. Example: getting to workman time? dealing with an ex? A health issue?
How often do you have a bowel movement?(Required)
Please enter a number from 1 to 7.
Type 1: Separate hard lumps, like nuts (hard to pass) Type 2: Lumpy and sausage like Type 3: A sausage shape with cracks in the surface Type 4: Like a sausage or snake, smooth and soft Type 5: Soft blogs with clear-cut edges Type 6: Fluffy pieces with ragged edges, a mushy stool Type 7: Liquid consistency with no solid pieces

Wrap Up!!

Max. file size: 977 MB.
1. Forward: No jacket or bulky clothes. Stand comfortably hand on each side 2. Backward: No loose tops. Wear clothing that are snug but not tight 3. Right side & Left side: Barefeet are best. Short sleeves. Head Straight Up and Hands on each Side.

General Consent of Participation:

All forms are located on the bottom of the website for your review.
Consent(Required)
Consent(Required)
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