TDG HealthStory Questionnaire v2

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Client Information

Basic details and primary complaints. Complete before the consultation.

Client Name

Date of Birth

Assessment Date

Primary Complaints (top 3)

Duration of main concerns

Current Medications

Current Supplements

Complete client details to begin

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Section A — Inherited Context

Family health patterns and parental health at conception. The terrain you were born into.

0

/ 6

Inherited Load

Early-onset conditions in family? (heart attack before 60, cancer before 50, etc.)

Section A — Score

Inherited Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Early-onset conditions in family +1 Multiple generations affected +1 Significant parental health factors at conception

0 = No significant family history | 1–2 conditions | 3–5 conditions | 3 = Extensive history (6+ conditions)

Inherited Load: 0 / 6

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Section B — Gestational & Birth

Pregnancy, delivery, and the immediate postnatal period. First loading events — the foundation.

0

/ 6

Birth Load

B1. Pregnancy Factors

Section B — Score

Birth Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Antibiotics during / after birth +1 Significant separation from mother +1 NICU / special care

0 = Uncomplicated vaginal birth | 1 = Minor intervention | 2 = Planned C-section | 3 = Emergency C-section or significant complications

Birth Load: 0 / 6

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Section C — Early Childhood (0–7 years)

Microbiome development, immune programming, environmental influences.

0

/ 10

Early Childhood

Section C — Score

Early Childhood Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Multiple antibiotic courses (5+) +1 Significant vaccine reactions +2 Significant family stress or trauma

0 = Minimal issues | 1 = 3–5 items | 2 = 6–10 items | 3 = Extensive issues (10+)

C — Key Notes

Early Childhood Load: 0 / 10

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Section D — Childhood & Adolescence (7–18 years)

Growth, development, identity formation, hormonal development.

0

/ 10

Adolescence

Section D — Score

Adolescence Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Overtraining / eating disorder +1 Mental health issues +1 Regular substance use

D — Key Notes

Adolescence Load: 0 / 10

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Section E — Young Adulthood (18–30 years)

Independence, exploration, foundation of adult lifestyle patterns.

0

/ 10

Young Adult

Section E — Score

Young Adult Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Heavy alcohol / substance use +1 Major stress / trauma event +1 Pregnancy complications

E — Key Notes

Young Adult Load: 0 / 10

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Section F — Adulthood (30–50 years)

Peak demands — career, family, accumulating load.

0

/ 10

Adulthood

Section F — Score

Adulthood Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

+1 Multiple bereavements +1 Significant caring burden +1 Burnout episode

F — Key Notes

Adulthood Load: 0 / 10

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Section G — Present State

Current health status, diagnoses, medications.

G2. Current Diagnoses

G3. Current Medications

G4. Current Supplements

G5. Recent Health Events (Last 5 Years)

Present state documented

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Section H — Inflection Points

The pivotal moments where health trajectory changed. Often the most diagnostically important part of the HealthStory.

H1. "Never Well Since…"

Is there a specific event after which you were never quite the same?

★ "Never Well Since" Event

Age / Year

Event Description

What changed after this event

H2. Last Time Felt Truly Well

Approximate Age / Year

What was different then?

What happened around the time things changed?

H3. Major Turning Points Up to 5

H4. Patterns You've Noticed

Inflection Point Modifiers

These add directly to your total load score

A client with a clear "Never Well Since" event and 3 turning points adds +5 to their total.

Inflection modifiers: +0

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Sections I & J — Your Understanding & Final Reflections

What you believe, what you've tried, and what you're hoping to achieve.

I1. What do you think caused your current health issues?

I2. What have you already tried?

I3. What helped, even partially?

I4. What made things worse?

I5. What are you most hoping to achieve?

Section J

J1. Anything else about your story?

J2. What's most important for Stephen to know about your situation?

Questionnaire complete

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Health Story — Load Assessment Summary

Complete picture of accumulated load, systems of concern, and testing priorities.

0

/ 46+

Total Accumulated Load

—

Complete all sections to generate interpretation.

Phase Breakdown

Load Accumulation Timeline

Birth

7

18

30

50

Now

Primary Systems of Concern — Based on HealthStory

Recommended Testing Order

Rank	Test	Rationale from History

History-Based Hypotheses

Client Communication Summary

"Looking at your history, I can see that..."

Your foundation was... (inherited + birth factors) Through childhood and adolescence... The turning point(s) appear to be...

"What this means is that your current symptoms make complete sense given everything your body has been through. This isn't random. This isn't your fault. This is your body doing its best with accumulated load. Context, not destiny. Clues, not verdicts."

Key Observations & Red Flags

Expected Timeline

1–3 months3–6 months6–12 months12+ months

Total Load: 0 / 46+ | —

Client Information

Section A — Inherited Context

Inherited Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section B — Gestational & Birth

Birth Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section C — Early Childhood (0–7 years)

Early Childhood Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section D — Childhood & Adolescence (7–18 years)

Adolescence Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section E — Young Adulthood (18–30 years)

Young Adult Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section F — Adulthood (30–50 years)

Adulthood Load Score (0–3 base, +1 per modifier)

Modifiers (+1 each)

Section G — Present State

Section H — Inflection Points

★ "Never Well Since" Event

These add directly to your total load score

Sections I & J — Your Understanding & Final Reflections

Health Story — Load Assessment Summary

Phase Breakdown

Load Accumulation Timeline

Primary Systems of Concern — Based on HealthStory

Recommended Testing Order

History-Based Hypotheses

Client Communication Summary

Send your Health Story Questionnaire to Stephen