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 Please take the following Chronic Disease Assessment (CDA)™️
 Please take the following Chronic Disease Assessment (CDA)™️
This is a detailed questionnaire to establish your life risk "portfolio."  It represents the COLLECTION of little risks that may be impacting your current and future health. This form does NOT constitute a diagnosis and your data in managed in strict compliance with HIPAA privacy laws.
125Questions
NSSC Chronic Disease Assessment (CDA)™️
Language
  • English (US)
  • Spanish (Latin America)
  • 1
    Please fill in all fields
    • Male
    • Female
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  • 2
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  • 3
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  • 4
    Only select those you had for 1 YEAR or more (scroll to see ALL)
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  • 5
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  • 6
    Only enter those you have lived in for MORE THAN 1 YEARS. If non-U.S. Indicate Canada, Mexico, or enter your home country.
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  • 7
    Only select countries or regions where you have stayed 1 MONTH or more.
    • Not Applicable
    • Africa
    • Asia
    • Australia/New Zealand
    • Canada
    • Caribbean
    • Central America/Mexico
    • South America
    • Europe
    • Other
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  • 8
    Please select all that apply.
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  • 9
    Pick only ONE
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  • 10
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  • 11
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  • 12
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  • 13
    Don't just consider today. Instead rate your health based on the past year.
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  • 14
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  • 15
    Consider both friends and family when answering this.
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  • 16
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  • 17
    Choose any that REGULARLY impact your daily activities.
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  • 18
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  • 19
    Chose all applicable answers from dropdown.
    • Childhood Trauma (Death in Family, Abuse)
    • Finances
    • Work, Job or School
    • Discrimination or Bullying
    • Post Traumatic Stress (PTSD)
    • Child Issue (Health, Behavior, School)
    • Personal Relationships
    • Health
    • Divorce
    • Pregnancy
    • Major Life Change
    • Lack of Time (Frustration)
    • Care of Elderly Family Member
    • Other
    • None / Not Applicable
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  • 20
    Pick only one - or enter in "Other"
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  • 21
    Pick ALL that apply.
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  • 22
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  • 23
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  • 24
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  • 25
    Please select all that apply.
    • Mold
    • Tree Bark
    • Animal Dander
    • Latex
    • Cleaning Agents
    • Grass
    • Dust Mites
    • Cockroaches
    • Alcohol
    • Pollen
    • Insect Stings
    • Chemicals
    • One or More Medicines
    • None
    • Not Sure
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  • 26
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  • 27
    Choose all that apply AT LEAST once each week or answer "nothing."
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  • 28
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  • 29
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  • 30
    Pick from a value or add your own in "Add Note Here.."
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  • 31
    • None
    • Eye Cover
    • Ear Plugs
    • White Noise
    • Sleeping Pills
    • Antihistamines
    • Sedatives
    • Melatonin
    • Valerian
    • Mood Drug (depression, anxiety type)
    • Alcoholic Drink
    • Complete Darkness
    • Nyquil or other OTC Drug
    • Melatonin
    • Other (not listed)
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  • 32
    • Alpha Lipoic Acid
    • Amino acid(s) like beta Alanine
    • Antioxidant (Vitamin E, NAC, other - NOT Vitamin C)
    • B Vitamin(s)
    • Blue-Green algae, chlorophyll, chlorella, or similar
    • Caffeine, ginseng or other stimulant
    • Calcium
    • Choline
    • Creatine, hormone (DHEA) or other muscle builder
    • Coconut oil
    • Cod liver oil
    • Coenzyme Q10 (CoQ10), Ubiquinone, Ubiquinol
    • Folic Acid or Folate
    • Garlic
    • Iron
    • L-Arginine, Citrulline, or other nitric oxide booster
    • Magnesium
    • Methylating Supplement (Betaine, SAM-e, Folate, B-12, TMG, MSM)
    • Mineral supplement (without vitamins)
    • Multivitamin and Mineral
    • Niacin
    • Omega-3 Supplement, Fish oil, Krill Oil
    • Probiotic
    • Protein powder or bar
    • Potassium
    • Psyillium or other form of soluble fiber
    • Turmeric (Curcumin) or other spices as a supplement
    • Vitamin C
    • Vitamin D
    • Vitamin K2
    • Other supplement(s) not listed
    • None - I don't take supplements
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  • 33
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  • 34
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  • 35
    If you have in the last 10 years click on "YES"
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  • 36
    Select ALL that apply.
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  • 37
    If you drink less than 1 time each week, answer "NO"
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  • 38
    Select ALL that apply.
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  • 39
    • Never Used / Not Applicable
    • Marijuana
    • Heroin
    • Heroin Sharing Needles
    • Ecstasy
    • Opium
    • Barbiturates/Benxodiazepines
    • Amphetamines
    • Cocaine
    • Solvents
    • LSD
    • Psychedelic Mushrooms
    • Other
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  • 40
    Please choose ALL that apply.
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  • 41
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  • 42
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  • 43
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  • 44
    Select ALL that apply.
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  • 45
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  • 46
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  • 47
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  • 48
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  • 49
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  • 50
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  • 51
    Pick the  SINGLE best answer
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  • 52
    Do NOT include wisdom teeth, baby teeth or teeth lost in an accident.
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  • 53
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  • 54
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  • 55
    Choose no more than 6 entries.
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  • 56
    Indicate what you do most regularly. Choose up to 6 entries
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  • 57
    Indicate how often you snack and what you choose.
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  • 58
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  • 59
    Do not include pre-packaged, frozen, microwaveable, canned or take-out meals.
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  • 60
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  • 61
    If your restaurant isn't listed, pick one that serves similar foods.
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  • 62
    This includes foods like Nuts, Butter, grass-fed Meats, Avocado and Coconut Oil, Olive Oil, Chia, Hemp, or Flax Seeds. It also includes other saturated, mono-unsaturated or omega-3 containing fats not listed here. This question does not pertain to cooking oils.
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  • 63
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  • 64
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  • 65
    Because of taste, cost, dietary restriction, or personal reasons. Pick no more than 6.
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  • 66
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  • 67
    Pickles, Slaw, Yogurt, Raw Cheese, Kefir, Sauerkraut, Miso, Tempeh, Kimchi, Natto are examples.
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  • 68
    Most restaurants use omega-6 oils like soybean, corn, vegetable and canola.
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  • 69
    Do you use refined, raw or natural sugars?
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  • 70
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  • 71
    Also - please indicate how it has changed - if you have changed your diet from the past.
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  • 72
    Consider your eating style over the past year.
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  • 73
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  • 74
    .
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  • 75
    .
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  • 76
    .
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  • 77
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  • 78
    1 capsule is about 1 gram.
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  • 79
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  • 80
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  • 81
    Do NOT include Vitamin C when answering this question.
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  • 82
    Answer this if your depression interferes with your daily living. If you haven't had depression for 10 years or more, answer "Never / Not applicable." Pick ALL that apply.
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  • 83
    Answer this if your ANXIETY interferes with your daily living.
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  • 84
    Also - Indicate if your memory has changed since last year. Select ALL that Apply.
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  • 85
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  • 86
    Select  up to the TOP 3 answers
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  • 87
    Choose those that may have caused you harm in the past and now.
    • None / Not Applicable
    • None Known
    • Mold
    • Metal Dust or Fume / Heavy Metals
    • Lead (Paint for Example)
    • Pesticides
    • Radiation (Natural, Medical/Treatment, Nuclear Plant)
    • Asbestos
    • Mercury
    • Fertilizers
    • Frequent X-Ray (Cat Scan, Chest or Teeth X-Rays)
    • Cleaning Agents
    • Infection from Exposure (TB, STD, Other)
    • Virus from Exposure (HIV/AIDS, HPV, Ebola)
    • Air Pollution
    • Water Contamination (E-Coli, Metals, Fluoride, Industrial Chemicals)
    • Fire/Combustion (Smoke inhalation)
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  • 88
    Please select by treatment target - NOT medication name.  TOP 5 ONLY.
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  • 89
    Bugs carry disease. Think way back in time and consider where you have lived or travelled.
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  • 90
    Also, please provide an explanation in "Other / Explain."
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  • 91
    Also, please provide an explanation in "Other / Explain."
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  • 92
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  • 93
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  • 94
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  • 95
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  • 96
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  • 97
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  • 98
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  • 99
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  • 100
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  • 101
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  • 102
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  • 103
    Select ALL that apply to you
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  • 104
    Include procedures. Select ALL that apply to you
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  • 105
    Select ALL that apply to you
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  • 106
    Select ALL that apply to your
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  • 107
    Select ALL that apply to you
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  • 108
    Select ALL that apply to you
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  • 109
    Select ALL that apply to you
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  • 110
    Select ALL that apply to you
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  • 111
    Select ALL that apply to you
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  • 112
    Select ALL that apply to you
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  • 113
    Select ALL that apply to you
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  • 114
    Select ALL that apply to you
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  • 115
    Select ALL that apply to you
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  • 116
    Select ALL that apply to you
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  • 117
    Select ALL that apply to you
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  • 118
    Select ALL that apply to you
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  • 119
    Select ALL that apply to you
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  • 120
    Select ALL that apply to you
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  • 121
    Select ALL of these immunomodulatory drugs that apply to you
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  • 122
    Provide the upper (higher number) and add comments - optional.
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  • 123
    60 inches = 5 feet; 72 inches = 6 feet
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  • 124
    2.2 pounds = 1 kilogram
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  • 125
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  • 126
    SELECT THE BEST ONE ONLY
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  • 127
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  • 128
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  • 129
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  • 130
    Your stools tell a story about digestion, absorption, detoxification - and overall health. Answer ALL that apply.
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  • 131
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  • 132
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  • 133
    MOTIVATIONS: Family, Wedding, Energy, Grand kids - are examples
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  • 134
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  • 135
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  • 136
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  • 137
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  • 138
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  • 139
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  • 140
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  • 141
    Click SUBMIT on the lower right corner to save and exit.
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