Health Questionnaire

Many health issues don’t develop overnight—they build up over time, much like a rain barrel slowly filling with water. When your body’s natural capacity to handle stress, toxins, and imbalances overflows, symptoms appear. This is why one person might experience bloating and brain fog, while another might struggle with joint pain and skin issues—different systems of the body become overwhelmed in different ways. The following questionnaire can be used to help you understand what symptoms you are experiencing.

This questionnaire beneath the video was developed by Dr. Stephen Cabral. Dr. Cabral explains the Rain Barrel Effect in the following video.

By using this questionnaire, you can:

  • Identify patterns in your health that you may not have noticed before
  • Recognize early warning signs before they become bigger problems
  • Bring valuable information to your provider to support deeper conversations about your health
  • Make more informed decisions about diet, lifestyle, and supplements

1. Headaches or Migraines?




2. Dizziness or Faintness




3. Neck Tension




4. Brain Fog or Cloudy Head




5. Nasal congestion (stuffy nose)




6. Allergies (seasonal or daily)




7. Mucus




8. Sneezing




9. Nose Blowing




10. Dark circles under eyes




11. Bags under eyes




12. Itchy eyes




13. Discharge or watery eyes




14. Blurred vision




15. Crusted eyes upon waking




16. Itchy Ears




17. Discharge or drainage from ears




18. Ringing in ears (tinnitus)




19. Excessive wax build up




20. Blocked or muffled hearing




21. Pain in gums or teeth (stuffy nose)




22. Bleeding gums




23. Silver fillings




24. Metal crowns or root canals




25. Canker sores




26. Cold sores




27. Discolored lips




28. White film on lips upon waking or after eating




29. Red dots on tongue




30. Sides of tongue have dents (scalloping) (stuffy nose)




31. White, yellow, or brown coating on tongue




32. Cracks or lines on tongue




33. Swollen lymph nodes (neck, armpits, or groin)




34. Difficulty swallowing




35. Loss of voice




36. Swollen ankles or wrists/hands/fingers




37. Chest tension




38. Chronic cough




39. Clear throat a lot




40. Voice hoarseness




41. Difficulty losing weight




42. Gain weight easily




43. Feel swollen or puffy




44. Retain water




45. Pain in joints




46. Muscle stiffness




47. Limited range of motion




48. Muscle weakness or loss of strength




49. Arthritis




50. Acne




51. Hair loss




52. Flushing or hot flashes




53. Dry, flaky skin




54. Excessive sweating




55. Hives or itchiness




56. Psoriasis, eczema, ringworm or skin rashes




57. Inability to fall asleep




58. Can’t stay asleep/Wake up frequently




59. Nightmares




60. Heart racing at night




61. Night sweats




62. Tired upon waking




63. Daytime or afternoon fatigue




64. General lack of energy




65. Apathy




66. Lack of ambition or drive




67. Lack of ambition or drive




68. Restlessness (feel uncomfortable with quiet)




69. Tap feet or shake leg or hands when seated




70. Decreased libido or sexual function




71. Get tired after meals (especially lunch)




72. Bloating




73. Gas




74. Belching/Burping




75. Heartburn or indigestion




76. Diarrhea




77. Constipation




78. Stomach or intestinal pain




79. Nausea or vomiting




80. Stomach sticks out more as day progresses




81. Lack of concentration




82. Easily distracted or lose train of thought




83. Difficulty making decisions




84. Brain fog




85. Stuttering or difficulty putting together sentences




86. Uncoordinated or drop things




87. ADD/ADHD or learning disabilities




88. Anxiety




89. Overwhelm




90. Irritability




91. Anger or rage




92. Dark thoughts




93. Sad for no reason




94. Mood swings




95. Depressed




96. High-strung




97. Seasonal Affective Disorder (SAD)




98. Frequent Colds (more than 2-3 illnesses a year)


99. Allergies (environmental or non-fatal food sensitivities)


100. Pneumonia (within the last 12 months)


101. Diagnosed disease


102. Unexplained illness