{ "formId": "hw_health_questionnaire", "formName": "Harmonious Wellness Health Questionnaire", "version": "2026-01-04", "owner": "Harmonious Wellness (Kelly Shay)", "settings": { "allowSaveAndResume": true, "showProgressBar": true, "defaultRequiredMessage": "This field is required.", "ui": { "layout": "multi_step", "sectionStyle": "cards" } }, "logicConventions": { "operators": ["eq", "neq", "in", "contains", "gt", "gte", "lt", "lte", "truthy"], "notes": [ "Use visibility.whenAll/whenAny arrays of conditions.", "Use 'text_contains' style logic via 'contains' operator on string fields." ] }, "sections": [ { "id": "demographics", "title": "Demographics", "description": "Basic identifying and contact details.", "fields": [ { "id": "first_name", "label": "First Name", "type": "text", "required": true, "placeholder": "First name" }, { "id": "last_name", "label": "Last Name", "type": "text", "required": true, "placeholder": "Last name" }, { "id": "gender", "label": "Gender", "type": "select", "required": true, "options": [ { "value": "female", "label": "Female" }, { "value": "male", "label": "Male" }, { "value": "nonbinary", "label": "Non-binary" }, { "value": "prefer_not_to_say", "label": "Prefer not to say" } ] }, { "id": "age", "label": "Age", "type": "number", "required": true, "min": 0, "max": 120 }, { "id": "height", "label": "Height", "type": "text", "required": true, "placeholder": "e.g., 5'8\" or 173 cm" }, { "id": "weight", "label": "Weight", "type": "text", "required": true, "placeholder": "e.g., 165 lb or 75 kg" }, { "id": "email", "label": "Email Address", "type": "email", "required": true, "placeholder": "name@email.com" }, { "id": "location_time_zone", "label": "Location / Time Zone", "type": "text", "required": true, "placeholder": "City, State and Time Zone" }, { "id": "phone_number", "label": "Phone Number", "type": "phone", "required": true, "placeholder": "(555) 555-5555" }, { "id": "preferred_communication_method", "label": "Preferred Communication Method", "type": "select", "required": true, "options": [ { "value": "text", "label": "Text" }, { "value": "email", "label": "Email" }, { "value": "phone", "label": "Phone Call" } ] } ] }, { "id": "primary_concerns_history", "title": "Primary Concerns and Medical History", "description": "Your main concerns and key medical background.", "fields": [ { "id": "main_health_concerns", "label": "Main Health Concerns you'd like support on", "type": "textarea", "required": true, "placeholder": "Briefly describe your top concerns." }, { "id": "diagnosed_medical_conditions", "label": "Diagnosed Medical Conditions", "type": "textarea", "required": true, "placeholder": "List diagnoses or type “None”." }, { "id": "current_medications", "label": "Current Medications", "type": "text", "required": true, "placeholder": "List medications or type “None”." }, { "id": "current_supplements", "label": "Current Supplements", "type": "text", "required": true, "placeholder": "List supplements or type “None”." }, { "id": "past_major_surgeries", "label": "Past Major Surgeries", "type": "text", "required": true, "placeholder": "List surgeries or type “N/A”." }, { "id": "pregnant_or_breastfeeding", "label": "Pregnant or Breastfeeding", "type": "boolean", "required": true, "visibility": { "whenAll": [ { "field": "gender", "op": "eq", "value": "female" } ] } }, { "id": "gallbladder_removed", "label": "Gallbladder Removed", "type": "boolean", "required": true }, { "id": "history_of_heart_issues", "label": "History of Heart Issues (Arrhythmia, Stent, Pacemaker, etc.)", "type": "text", "required": true, "placeholder": "Describe or type “N/A”." }, { "id": "cancer_history_explain", "label": "Cancer History (Please explain)", "type": "text", "required": true, "visibility": { "whenAny": [ { "field": "diagnosed_medical_conditions", "op": "contains", "value": "cancer" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "Cancer" } ] }, "placeholder": "Type and location, or “N/A”." }, { "id": "diabetes_type", "label": "Diabetes Type", "type": "select", "required": true, "options": [ { "value": "none", "label": "None" }, { "value": "type_1", "label": "Type 1" }, { "value": "type_2", "label": "Type 2" }, { "value": "unsure", "label": "Unsure" } ] }, { "id": "kidney_disease", "label": "Kidney Disease", "type": "boolean", "required": true, "visibility": { "whenAny": [ { "field": "diagnosed_medical_conditions", "op": "contains", "value": "kidney" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "Kidney" } ] } }, { "id": "liver_hepatitis_history", "label": "Liver/Hepatitis History", "type": "boolean", "required": true, "visibility": { "whenAny": [ { "field": "diagnosed_medical_conditions", "op": "contains", "value": "liver" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "Liver" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "hepatitis" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "Hepatitis" } ] } }, { "id": "known_allergies_food_environmental", "label": "Known Allergies (Food/Environmental)", "type": "text", "required": true, "placeholder": "List allergies or type “N/A”." } ] }, { "id": "gi_digestion", "title": "Digestion and Elimination", "description": "Digestive function, reactions, and stool patterns.", "fields": [ { "id": "overall_digestion", "label": "Overall Digestion", "type": "scale", "required": true, "min": 0, "max": 5, "minLabel": "Very poor", "maxLabel": "Excellent" }, { "id": "bloating_after_meals", "label": "Bloating After Meals", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "reaction_to_fats", "label": "Reaction to Fats", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "gas_frequency", "label": "Gas Frequency", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "constipation_tendency", "label": "Constipation Tendency", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "diarrhea_tendency", "label": "Diarrhea Tendency", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "stool_form_bristol", "label": "Stool Form (Bristol Scale)", "type": "select", "required": true, "options": [ { "value": "1", "label": "Type 1 (hard lumps)" }, { "value": "2", "label": "Type 2 (lumpy sausage)" }, { "value": "3", "label": "Type 3 (cracked sausage)" }, { "value": "4", "label": "Type 4 (smooth sausage)" }, { "value": "5", "label": "Type 5 (soft blobs)" }, { "value": "6", "label": "Type 6 (mushy)" }, { "value": "7", "label": "Type 7 (watery)" } ] }, { "id": "stool_frequency", "label": "Stool Frequency", "type": "select", "required": true, "options": [ { "value": "0_1", "label": "0–1 per day" }, { "value": "1_2", "label": "1–2 per day" }, { "value": "2_3", "label": "2–3 per day" }, { "value": "3_plus", "label": "3+ per day" } ] }, { "id": "food_sensitivities", "label": "Food Sensitivities", "type": "text", "required": false, "placeholder": "List foods or type “N/A”." }, { "id": "acid_reflux_heartburn", "label": "Acid Reflux / Heartburn", "type": "scale", "required": true, "min": 0, "max": 5 } ] }, { "id": "energy_metabolic", "title": "Energy and Metabolic Signals", "description": "Energy patterns, weight patterns, and cravings.", "fields": [ { "id": "daily_energy_level", "label": "Daily Energy Level", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "midday_crashes", "label": "Midday Crashes", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "morning_fatigue", "label": "Morning Fatigue", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "over_or_under_weight", "label": "Are you Overweight or Underweight?", "type": "select", "required": true, "options": [ { "value": "overweight", "label": "Overweight" }, { "value": "underweight", "label": "Underweight" }, { "value": "neither", "label": "Neither" } ] }, { "id": "easy_gain_hard_lose", "label": "Easy to Gain Weight & Hard to Loose It?", "type": "boolean", "required": false }, { "id": "blood_sugar_symptoms", "label": "Blood Sugar Symptoms", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "cravings_sweets_salt_caffeine", "label": "Cravings (Sweets/Salt/Caffeine)", "type": "select", "required": true, "options": [ { "value": "none", "label": "None" }, { "value": "sweets", "label": "Sweets" }, { "value": "salt", "label": "Salt" }, { "value": "caffeine", "label": "Caffeine" }, { "value": "multiple", "label": "Multiple" } ] } ] }, { "id": "hormones_repro", "title": "Hormones and Reproductive Health", "description": "Hormonal symptoms and sex-specific health signals.", "fields": [ { "id": "hormonal_imbalance_symptoms", "label": "Hormonal Imbalance Symptoms", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "temperature_sensitivity", "label": "Temperature Sensitivity", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "hot_flashes_night_sweats", "label": "Hot Flashes / Night Sweats", "type": "boolean", "required": true }, { "id": "libido_level", "label": "Libido Level", "type": "select", "required": true, "options": [ { "value": "low", "label": "Low" }, { "value": "moderate", "label": "Moderate" }, { "value": "high", "label": "High" } ] }, { "id": "cycle_regularity", "label": "Cycle Regularity", "type": "boolean", "required": true, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "pms_severity", "label": "PMS Severity", "type": "scale", "required": true, "min": 0, "max": 5, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "menstrual_pain", "label": "Menstrual Pain", "type": "scale", "required": true, "min": 0, "max": 5, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "menopause_perimenopause_symptoms", "label": "Menopause or Perimenopause Symptoms", "type": "scale", "required": true, "min": 0, "max": 5, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "prostate_symptoms", "label": "Prostate Symptoms", "type": "boolean", "required": true, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "male" }] } }, { "id": "erectile_function_concerns", "label": "Erectile Function Concerns", "type": "boolean", "required": true, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "male" }] } } ] }, { "id": "sleep_stress_emotions", "title": "Sleep, Stress, and Emotional Health", "description": "Sleep quality and nervous system load.", "fields": [ { "id": "sleep_quality", "label": "Sleep Quality", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "time_to_fall_asleep", "label": "Time to Fall Asleep", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "difficulty_staying_asleep", "label": "Difficulty Staying Asleep", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "difficulty_falling_asleep", "label": "Difficulty Falling Asleep", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "overall_stress_level", "label": "Overall Stress Level", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "anxiety_level", "label": "Anxiety Level", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "overthinking_rumination", "label": "Overthinking / Rumination", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "emotional_resilience", "label": "Emotional Resilience", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "major_trauma_stress_history", "label": "Major Trauma/Stress History", "type": "text", "required": false, "placeholder": "Briefly describe or type “N/A”." } ] }, { "id": "immune_lymph_skin", "title": "Immune, Lymphatic, Skin, and Cognitive", "description": "Immune resilience, lymph congestion signals, skin and cognition.", "fields": [ { "id": "swelling_puffiness", "label": "Swelling / Puffiness", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "skin_issues_acne_eczema_rashes", "label": "Skin Issues (Acne/Eczema/Rashes)", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "brain_fog", "label": "Brain Fog", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "frequent_colds_low_immunity", "label": "Frequent Colds or Low Immunity", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "sinus_congestion", "label": "Sinus Congestion", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "lymph_node_swelling", "label": "Lymph Node Swelling", "type": "scale", "required": false, "min": 0, "max": 5 }, { "id": "hair_loss_thinning", "label": "Hair Loss / Thinning", "type": "boolean", "required": false }, { "id": "autoimmune_diagnosis", "label": "Autoimmune Diagnosis", "type": "boolean", "required": true, "visibility": { "whenAny": [ { "field": "diagnosed_medical_conditions", "op": "contains", "value": "autoimmune" }, { "field": "diagnosed_medical_conditions", "op": "contains", "value": "Autoimmune" } ] } } ] }, { "id": "respiratory_cardio_movement", "title": "Respiratory, Cardiovascular, and Movement", "description": "Breathing, heart-related symptoms, and activity tolerance.", "fields": [ { "id": "shortness_of_breath", "label": "Shortness of Breath", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "exercise_intolerance", "label": "Exercise Intolerance", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "chest_tightness", "label": "Chest Tightness", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "chronic_cough", "label": "Chronic Cough", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "mucus_production", "label": "Mucus Production", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "smoking_or_exposure", "label": "Smoking or Exposure", "type": "boolean", "required": true }, { "id": "smoking_amount", "label": "If yes, how much? (amount or exposure details)", "type": "text", "required": false, "visibility": { "whenAll": [{ "field": "smoking_or_exposure", "op": "eq", "value": true }] }, "placeholder": "e.g., packs/day, cigarettes/day, secondhand exposure" }, { "id": "cardiovascular_symptoms_chest_pain_pressure_arrhythmia", "label": "Cardiovascular Symptoms (Chest pain, pressure, arrhythmia)", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "movement_frequency", "label": "Movement Frequency", "type": "select", "required": true, "options": [ { "value": "rarely", "label": "Rarely" }, { "value": "1_2_week", "label": "1–2x/week" }, { "value": "3_4_week", "label": "3–4x/week" }, { "value": "5_plus_week", "label": "5+ times/week" } ] } ] }, { "id": "lifestyle_hydration_exposure", "title": "Lifestyle, Hydration, and Exposures", "description": "Daily rhythm inputs and environmental/toxic load.", "fields": [ { "id": "sunlight_exposure", "label": "Sunlight Exposure", "type": "select", "required": true, "options": [ { "value": "low", "label": "Low" }, { "value": "moderate", "label": "Moderate" }, { "value": "high", "label": "High" } ] }, { "id": "workload_stress_load", "label": "Workload / Stress Load", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "hydration_level", "label": "Hydration Level", "type": "scale", "required": true, "min": 0, "max": 5 }, { "id": "type_of_water_consumed", "label": "Type of Water Consumed", "type": "select", "required": false, "options": [ { "value": "filtered", "label": "Filtered" }, { "value": "spring", "label": "Spring" }, { "value": "tap", "label": "Tap" }, { "value": "reverse_osmosis", "label": "Reverse Osmosis" }, { "value": "bottled", "label": "Bottled" }, { "value": "other", "label": "Other" } ] }, { "id": "alcohol_caffeine_intake", "label": "Alcohol / Caffeine Intake", "type": "select", "required": false, "options": [ { "value": "none", "label": "None" }, { "value": "low", "label": "Low" }, { "value": "moderate", "label": "Moderate" }, { "value": "high", "label": "High" } ] }, { "id": "heavy_metal_exposure", "label": "Heavy Metal Exposure", "type": "boolean", "required": true }, { "id": "mold_exposure", "label": "Mold Exposure", "type": "boolean", "required": true } ] }, { "id": "detox_case_history_goals", "title": "Detox History, Case History, and Intentions", "description": "Context for pacing, root causes, and your intention.", "fields": [ { "id": "past_detox_attempts", "label": "Past Detox Attempts", "type": "boolean", "required": false }, { "id": "past_detox_reactions", "label": "If yes, what happened? (reactions/notes)", "type": "text", "required": false, "visibility": { "whenAll": [{ "field": "past_detox_attempts", "op": "eq", "value": true }] }, "placeholder": "Short notes" }, { "id": "onset_of_condition_symptoms", "label": "Onset of condition symptoms (When did they begin?)", "type": "text", "required": true, "placeholder": "Approx date or timeframe" }, { "id": "root_triggers_identified", "label": "Root Triggers Identified", "type": "text", "required": false, "placeholder": "If you suspect any triggers (stress, mold, diet, etc.)" }, { "id": "major_life_events_around_onset", "label": "Major Life Events Around Onset", "type": "text", "required": false, "placeholder": "Anything significant around that time" }, { "id": "what_do_you_want_most_from_this_protocol", "label": "What Do You Want Most From This Protocol?", "type": "text", "required": true, "placeholder": "Your primary outcome" } ] }, { "id": "vitals_diet_family", "title": "Vitals, Diet, and Family History", "description": "Key anchors Kelly requested to see grouped and easy to reference.", "fields": [ { "id": "blood_pressure_right", "label": "Blood Pressure Right", "type": "text", "required": true, "placeholder": "e.g., 120/80 or type “N/A”" }, { "id": "blood_pressure_left", "label": "Blood Pressure Left", "type": "text", "required": true, "placeholder": "e.g., 120/80 or type “N/A”" }, { "id": "urine_ph", "label": "Urine pH", "type": "number", "required": true, "min": 0, "max": 14, "step": 0.1, "placeholder": "e.g., 6.5 or type “N/A”" }, { "id": "daily_diet_breakfast_lunch_dinner_snacks", "label": "What does your current daily diet consist of? (Breakfast/Lunch/Dinner/Snacks)", "type": "textarea", "required": true, "placeholder": "List typical breakfast, lunch, dinner, and snacks." }, { "id": "family_history_all", "label": "Please list all known health concerns for each family member (Mother/Father/Grandparents/Siblings). Leave blank if you aren’t sure.", "type": "textarea", "required": true, "placeholder": "Mother: ... Father: ... Grandparents: ... Siblings: ..." } ] }, { "id": "system_mapping_additions", "title": "System Mapping (Kelly’s Key Adds)", "description": "High-signal items reintroduced as explicit questions for clearer gland/system mapping.", "fields": [ { "id": "cold_hands_or_feet", "label": "Cold Hands or Feet", "type": "boolean", "required": true }, { "id": "cold_all_the_time", "label": "Cold All the Time", "type": "boolean", "required": true }, { "id": "are_your_fingernails", "label": "Are Your Fingernails:", "type": "select", "required": false, "options": [ { "value": "weak", "label": "Weak" }, { "value": "brittle", "label": "Brittle" }, { "value": "ridged", "label": "Ridged" }, { "value": "normal", "label": "Normal" } ]}, { "id": "muscle_weakness", "label": "Muscle Weakness", "type": "boolean", "required": false }, { "id": "varicose_veins", "label": "Varicose Veins", "type": "boolean", "required": false }, { "id": "hemorrhoids", "label": "Hemorrhoids", "type": "boolean", "required": false }, { "id": "prolapses", "label": "Prolapses", "type": "boolean", "required": true }, { "id": "muscle_cramps", "label": "Muscle Cramps", "type": "boolean", "required": true }, { "id": "low_bone_density", "label": "Low Bone Density", "type": "boolean", "required": true }, { "id": "osteoporosis", "label": "Osteoporosis", "type": "boolean", "required": true }, { "id": "scoliosis", "label": "Scoliosis", "type": "boolean", "required": true }, { "id": "mental_health_challenges_list", "label": "Mental Health Challenges (Depression, PTSD, OCD, etc.)", "type": "text", "required": true, "placeholder": "List challenges or type “N/A”." }, { "id": "poor_memory", "label": "Poor Memory", "type": "boolean", "required": true }, { "id": "lack_of_motivation", "label": "Lack of Motivation", "type": "boolean", "required": false }, { "id": "depression_binary", "label": "Depression", "type": "boolean", "required": true }, { "id": "slow_digestion_binary", "label": "Slow Digestion", "type": "boolean", "required": false }, { "id": "nervousness", "label": "Nervousness", "type": "boolean", "required": true }, { "id": "itis_condition_list", "label": "Do You Have Any “Itis” Condition (Arthritis, Osteoarthritis, Bursitis, etc.) — Please List", "type": "text", "required": false, "placeholder": "List or type “N/A”." }, { "id": "low_steroids_low_cortisol", "label": "Low Steroids / Low Cortisol", "type": "boolean", "required": true }, { "id": "add", "label": "ADD (Attention Deficit Disorder)", "type": "boolean", "required": true }, { "id": "adhd", "label": "ADHD (Attention Deficit Hyperactivity Disorder)", "type": "boolean", "required": true }, { "id": "autism", "label": "Autism", "type": "boolean", "required": true }, { "id": "fibroids", "label": "Fibroids", "type": "boolean", "required": true, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "endometriosis", "label": "Endometriosis", "type": "boolean", "required": true, "visibility": { "whenAll": [{ "field": "gender", "op": "eq", "value": "female" }] } }, { "id": "fats_dairy_bloat", "label": "Fats and dairy cause stomach bloat", "type": "boolean", "required": false }, { "id": "fats_dairy_pain", "label": "Fats and dairy cause stomach pain", "type": "boolean", "required": false }, { "id": "anemia", "label": "Anemia", "type": "boolean", "required": true }, { "id": "heart_attack", "label": "Heart Attack", "type": "boolean", "required": true }, { "id": "sleep_apnea", "label": "Sleep Apnea", "type": "boolean", "required": true }, { "id": "do_you_snore", "label": "Do You Snore?", "type": "boolean", "required": true }, { "id": "uti", "label": "UTI", "type": "boolean", "required": true }, { "id": "bladder_infection", "label": "Bladder Infection", "type": "boolean", "required": true }, { "id": "sciatica", "label": "Sciatica", "type": "boolean", "required": false }, { "id": "bags_under_eyes", "label": "Bags Under Eyes", "type": "boolean", "required": false }, { "id": "frequent_urination", "label": "Frequent Urination", "type": "boolean", "required": true }, { "id": "kidney_stones", "label": "Kidney Stones", "type": "boolean", "required": true }, { "id": "lower_back_pain", "label": "Lower Back Pain", "type": "boolean", "required": false } ] }, { "id": "treatments_vaccines_substances", "title": "Treatments, Vaccines, and Substances", "description": "Safety and detox context.", "fields": [ { "id": "chemo_or_radiation_history", "label": "Have You Gone Through Chemotherapy or Radiation?", "type": "boolean", "required": true }, { "id": "standard_vaccinations", "label": "Have You Received the “Standard” Vaccinations?", "type": "boolean", "required": true }, { "id": "travel_vaccinations", "label": "Have You Received Vaccinations for Travelling to Foreign Countries?", "type": "boolean", "required": true }, { "id": "flu_shot", "label": "Have You Received a Flu Shot?", "type": "boolean", "required": true }, { "id": "recreational_drugs_list", "label": "Please List Any ‘Recreational’ Drugs You Have Used:", "type": "text", "required": false, "placeholder": "List or type “N/A”." } ] } ], "dataExport": { "flattening": { "delimiter": ".", "includeHiddenFields": false }, "fieldMap": "use_field_ids_as_keys" } }