Dr. Jim Baughman Chiropractic Clinic and Nutritional Services Dr. Jim Baughman Chiropractic Clinic and Nutritional Services
To Set Up An Appointment,
call 724.836.5408
+ Dr. Jim Bio
+ Services
+ Take a Health Survey
+ Pain and/or Fatigue?
+ Anti-Aging
+ Hormone Balance
+ Cancer Awareness
+ Erase Wrinkles
+ Seminars
 
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Health Survey

Take this Health Survey and submit the results to Dr. Jim.
First Name: 
Last Name: 
Address: 
Address: 
City: 
State: 
Zip Code: 
Phone: 
Email Address: 
Part 1 - Pain & Toxicity Assessment Test
Use the drop down selection to answer Yes or No

If the total number of symptoms is 4 or greater, it might be due to toxic overload and you need a metabolic detox for pain inflammation and fatigue.
 Do you feel tied or fatigued?
 Do you experience early morning stiffness?
 Do you feel stiff after periods of rest?
 Do you feel dizzy, foggy-headed or have trouble concentrating?
 Do you experience cracking joints?
 Do you experience frequent back pain or headaches?
 Do you eat fast, fatty, processed or fried foods?
 Do you experience generalized aches and pains in the body?
 Do you use coffee, cigarettes, candy or soda to get energy?
 Are you sleepy in the afternoon?
 Do you bruise easily?
 Do you recover slowly from moderate exercise?
 Do you have food allergies, or are often exposed to chemicals,
 sedatives or stimulants?
 Do you take pain relievers to get rid of aches and pains?
 Do you have a family history of arthritis or auto-immune disorders?
 Total number of symptoms
 
Part 2 - Bio-Inflammation Symptoms Questionaire
Rate each of the following symptoms based upon your typical health profile:

Point Scale:
0 - Never or almost never have the symptoms
1 - Occassionally has it, effect is not severe
2 - Occassionally has it, effect is severe
3 - Frequently has it, effect is not severe
4 - Frequently has it, effect is severe

If any individual section total is 10 or more, or the Grand total is 50 or more, you may benefit from a detoxification program.
1. Digestive
 Nausea or Vomiting
 Diarrhea
 Constipation
 Bloated Feeling
 Belching, passing gas
 Heartburn
 Total
 
2. Emotions
 Mood swings
 Anxiety, fear or nervousness
 Anger, irritability
 Depression
 Total
 
3. Eyes
 Watery, itchy eyes
 Swollen, reddened or sticky eyelids
 Dark circles under eyes
 Blurred/tunnel vision
 Total
 
4. Lungs
 Chest Congestion
 Asthma, bronchitis
 Shortness of breath
 Difficulty breathing
 Total
 
5. Ears
 Itchy ears
 Earaches, ear infection
 Drainage from ear
 Ring in ears, hearing loss
 Total
 
6. Energy/Activity
 Fatigue, sluggishness
 Apathy, sluggishness
 Hyperactivity
 Restlessness
 Total
 
7. Head
 Headaches
 Faintness
 Dizziness
 Insomnia
 Total
 
8. Mind
 Poor memory
 Confusion
 Poor concentration
 Poor coordination
 Difficulty making decisions
 Stuttering, stammering
 Slurred speech
 Learning disabilities
 Total
 
9. Mouth/Throat
 Chronic coughing
 Gagging, need to clear throat
 Sore throat, hoarse
 Swollen or discolored tongue, gums or lips
 Canker sores
 Total
 
10. Skin
 Acne
 Hives, rashes or dry skin
 Hair loss
 Flushing or hot flashes
 Excessive sweating
 Total
 
11. Joint/Muscles
 Pain or aches in joints
 Arthritis
 Stiff, limited movement
 Pain, aches in muscles
 Weakness or tiredness
 Total
 
12. Nose
 Stuffy nose
 Sinus problems
 Hay fever
 Sneezing attacks
 Excessive mucus
 Total
 
13. Heart
 Skipped heartbeats
 Rapid heartbeats
 Chest pain
 Total
 
14. Weight
 Binge eating/drinking
 Craving certain foods
 Excessive weight gain
 Compulsive eating
 Water retention
 Underweight
 Total
 
15. Other
 Frequent illness
 Frequent/urgent urination
 Genital itch, discharge
 Total
 
  Grand Total Bio-Inflammation
 
Baughman Chiropractic Clinic and Nutritional Services
938 St. Clair Way, Greensburg, Pennsylvania 15601
724.836.5408 + Email: drjim@askingdrjim.com