CLICK HERE DOWNLOAD PDF FILE

General Information
Name
Age
Today’s Date
Not Set
Date of Birth
Not Set
Email
Address
City
State
Zip
Phone (Home)
(Cell)
(Work)
Genetic Background:
African AmericanHispanicMediterraneanAsianNative AmericanCaucasianNorthern EuropeanOther
If Other
When, where and from whom did you last receive medical or health care?
Emergency Contact:
Relationship
Phone (Home)
(Cell)
(Work)
How did you hear about our practice?
Clinic websiteIFM websiteReferral from doctorReferral from friend/family memberSocial mediaOther
If Other
Current Health Concerns
Please rank current and ongoing health concerns in order of priority
Describe Problem Severity
Example: Post Nasal Drip
MildModerateSevere
1.
MildModerateSevere
2.
MildModerateSevere
3.
MildModerateSevere
4.
MildModerateSevere
5.
MildModerateSevere
Prior Treatment/Approach Success
Elimination Diet
ExcellentGoodFair
1.
ExcellentGoodFair
2.
ExcellentGoodFair
3.
ExcellentGoodFair
4.
ExcellentGoodFair
5.
ExcellentGoodFair
Allergies
Name of Medication/Supplement/Food:
Reaction:
Lifestyle Review
Sleep
How many hours of sleep do you get each night on average?
Do you have problems falling asleep?
YesNo
Do you have problems with insomnia?
YesNo
Do you feel rested upon awakening?
YesNo
Do you use sleeping aids?
YesNo
If yes, explain:
Staying asleep?
YesNo
Do you snore?
YesNo
Exercise
Current Exercise Program:
Activity
Type
# of Times Per Week
Time/Duration (Minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (e.g., golf)
Other:
Do you feel motivated to exercise?
YesA littleNo
Are there any problems that limit exercise?
YesNo
If yes, explain:
Do you feel unusually fatigued or sore after exercise?
YesNo
If yes, explain:
Nutrition
Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)
VegetarianVeganAllergyEliminationLow FatLow CarbHigh ProteinBlood TypeLow sodiumNo DairyNo WheatGluten FreeOther:
If Other
Do you have sensitivities to certain foods?
YesNo
If yes, list food and symptoms:
Do you have an aversion to certain foods?
YesNo
If yes, explain:
Do you adversely react to: (Check all that apply)
Monosodium glutamate (MSG)Artificial sweetenersGarlic/onionCheeseCitrus foodsChocolateAlcoholRed wineSulfite–containing foods (wine, dried fruit, salad bars)PreservativesFood coloringsOther food substances:
If Other
Are there any foods that you crave or binge on?
YesNo
If yes, what foods?
Do you eat 3 meals a day?
YesNo
If no, how many
Does skipping a meal greatly affect you?
YesNo
How many meals do you eat out per week?
0–11–33–5>5 meals per week
Check the factors that apply to your current lifestyle and eating habits:
Fast eaterEat tomuchLate-night eatingDislike healthy foodsTime constraintsTravel frequentlyEat more than 50% of meals away from homeHealthy foods not readily availablePoor snack choicesSignificant other or family members don’t likehealthy foodsSignificant other or family membershave special dietary needsLove teatEat because I have toHave negative relationship tfoodStruggle with eating issuesEmotional eater (eat when sad, lonely, bored, etc.)Eat tomuch under stressEat tolittle under stressDon’t care tcookConfused about nutrition advice
Diet
Please record what you eat in a typical day:
Breakfast
Lunch
Dinner
Snacks
Fluids
How many servings do you eat in a typical week of these foods:
Fruits (not juice)
Vegetables (not including white potatoes)
Legumes (beans, peas, etc)
Red meat
Fish
Dairy/Alternatives
Nuts & Seeds
Fats & Oils
Cans of soda (regular or diet)
Sweets (candy, cookies, cake, ice cream, etc.)
Do you drink caffeinated beverages?
YesNo
If yes, check amounts:
Coffee (cups per day)
12-4>4
Tea (cups per day)
12-4>4
Caffeinated sodas—regular or diet (cans per day)
12-4>4
Do you have adverse reactions to caffeine?
YesNo
If yes, explain:
When you drink caffeine do you feel:
Irritable or wiredAches or pains
Smoking
Do you smoke currently?
YesNo
Packs per day:
Number of years
What type?
CigarettesSmokelessPipeCigarE-Cig
Have you attempted to quit?
YesNo
If yes, using what methods:
If you smoked previously:
Packs per day:
Number of years
Are you regularly exposed to second-hand smoke?
YesNo
Alcohol
How many alcoholic beverages do you drink in a week?
1–34–67–10>10None
(1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)
Previous alcohol intake?
Yes (Mild)Yes (Moderate)Yes (High)None
Have you ever had a problem with alcohol?
YesNo
If yes, when?
Explain the problem:
Have you ever thought about getting help to control or stop your drinking?
YesNo
Other Substances
Are you currently using any recreational drugs?
YesNo
If yes, type:
Have you ever used IV or inhaled recreational drugs?
YesNo
Stress
Do you feel you have an excessive amount of stress in your life?
YesNo
Do you feel you can easily handle the stress in your life?
YesNo
How much stress do each of the following cause on a daily basis  (Rate on scale of 1-10, 10 being highest)
Work
Family
Social
Finances
Health
Other
Do you use relaxation techniques?
YesNo
If yes, how often?
Which techniques do you use?
MeditationBreathingTai ChiYogaPrayerOther
(Check all that apply)
If Other:
Have you ever sought counseling?
YesNo
Are you currently in therapy?
YesNo
If yes, describe:
Have you ever been abused, a victim of crime, or experienced a significant trauma?
YesNo
What are your hobbies or leisure activities?
Relationships
Marital status:
SingleMarriedDivorcedGay/LesbianLong-Term PartnerWidow/er
With whom do you live? (Include children, parents, relatives, friends, pets)
Current occupation:
Previous occupations:
Do you have resources for emotional support?
YesNo
(Check all that apply)
Spouse/PartnerFamilyFriendsReligious/SpiritualPetsOther:
If Other
Do you have a religious or spiritual practice?
YesNo
If yes, what kind?
How well have things been going for you?    (Mark on scale of 1–10, or N/A if not applicable)
Poorly (1,2,3,4) - Fine (5,6,7,8,9) - Very Well (10)
Overall
N/A12345678910
At school
N/A12345678910
In your job
N/A12345678910
In your social life
N/A12345678910
With close friends
N/A12345678910
With sex
N/A12345678910
With your attitude
N/A12345678910
With your boyfriend/girlfriend
N/A12345678910
With your children
N/A12345678910
With your parents
N/A12345678910
With your spouse
N/A12345678910
History
Patient’s Birth/Childhood History:
You were born:
TermPrematureDon’t know
Were there any pregnancy or birth complications?
YesNo
If yes, explain:
You were:
Breast-fed/How long?
Bottle-fed/Type of formula
Don’t know
Age of introduction of:
Solid food:
Wheat
Dairy
As a child, were there any foods that were avoided because they gave you symptoms?
YesNo
If yes, what foods and what symptoms? (Example: milk—gas and diarrhea)
Did you eat a lot of sugar or candy as a child?
YesNo
Dental History:
Check if you have any of the following, and provide number if applicable:
Silver mercury fillings
Gold fillings
Root canals
Implants
Caps/Crowns
Tooth pain
Bleeding gums
Gingivitis
Problems with chewing
Other dental concerns (explain):
Have you had any mercury fillings removed?
YesNo
If yes, when:
How many fillings did you have as a kid?
Do you brush regularly?
YesNo
Do you floss regularly?
YesNo
Environmental/Detoxification History
Do any of these significantly affect you?
Cigarette smokePerfume/colognesAuto exhaust fumesOther
If Other
In your work or home environment are you regularly exposed to:
MoldWater leaksRenovationsChemicalsElectromagnetic radiationDamp environmentsCarpets or rugsOld paintStagnant or stuffy airSmokersPesticidesHerbicidesHarsh chemicals (solvents, glues, gas, acids, etc)Cleaning chemicalsHeavy metals (lead, mercury, etc.)PaintsAirplane travelOther
(Check all that apply)
If Other
Have you had a significant exposure to any harmful chemicals?
YesNo
If yes: Chemical name, length of exposure, date:
Do you have any pets or farm animals?
YesNo
If yes, do they live:
InsideOutsideBoth inside and outside
Women’s History
Obstetric History: (Check box and provide number if applicable)
Pregnancies
Miscarriages
Abortions
Living children
Vaginal deliveries
Cesarean
Term births
Premature birth
Birth weight of largest baby
Birth weight of smallest baby
Did you develop any problems in or after pregnancy, for example, toxemia (high blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.?
YesNo
If yes, please explain
Menstrual History:
Age at first period
Date of last menstrual period
Length of cycle
Time between cycles
Cramping?
YesNo
Pain?
YesNo
Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)?
YesNo
If yes, please describe:
Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)?
YesNo
If yes, please describe:
Use of hormonal birth control:
Birth control pillsPatchNuva ringOther
If Other
How Long
Any problems with hormonal birth control?
YesNo
If yes, explain
Use of other contraception?
YesNoCondomsDiaphragmIUDPartner vasectomy
Are you in menopause?
YesNo
If yes, age at last period:
Was it surgical menopause?
YesNo
If yes, explain surgery:
Do you currently have symptomatic problems with menopause?
Hot flashesMood swingsConcentration/memory problemsHeadachesJoint painVaginal drynessWeight gainDecreased libidoLoss of control of urinePalpitations
(Check all that apply)
Are you on hormone replacement therapy?
YesNo
If yes, for how long and for what reason (hot flashes, osteoporosis prevention, etc.)?
Other Gynecological Symptoms: (Check if applicable)
EndometriosisInfertilityFibrocystic breastsVaginal infectionFibroidsOvarian cystsPelvic inflammatory diseaseReproductive cancerSexually transmitted disease (describe)
Sexually transmitted disease (describe)
If choose Sexually transmitted disease
Gynecological Screening/Procedures:  (If applicable, provide date)
Last Pap test:
NormalAbnormal
Last mammogram:
NormalAbnormal
Last bone density:
Results:
HighLowWithin Normal Range
Other tests/procedures (list type and dates)
Family History:
Check family members that have/had any of the following
Age (if still alive)
Mother
Father
Brother (s)
Sister (s)
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Age at death (if deceased)
Mother
Father
Brother (s)
Sister (s)
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Cancer
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Heart disease
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Hypertension
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Obesity
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Diabetes
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Stroke
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Autoimmune disease
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Arthritis
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Kidney disease
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Thyroid problems
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Seizures/epilepsy
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Psychiatric disorders
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Anxiety
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Depression
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Asthma
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Allergies
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Eczema
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
ADHD
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Autism
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Irritable Bowel Syndrome
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Dementia
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Substance abuse
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Genetic disorders
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Other:
MotherFatherBrother (s)Sister (s)ChildChildChildMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherOther
Medical History: Illnesses/Conditions
Check YES = a condition you currently have, Check PAST = a condition you’ve had in the past.
Gastrointestinal
Irritable bowel syndrome
YesPast
GERD (reflux)
YesPast
Crohn’s disease/ulcerative colitis
YesPast
Peptic ulcer disease
YesPast
Celiac disease
YesPast
Gallstones
YesPast
Other:
YesPast
Respiratory
Bronchitis
YesPast
Asthma
YesPast
Emphysema
YesPast
Pneumonia
YesPast
Sinusitis
YesPast
Sleep apnea
YesPast
Other:
YesPast
Urinary/Genital
Kidney stones
YesPast
Gout
YesPast
Interstitial cystitis
YesPast
Frequent yeast infections
YesPast
Frequent urinary tract infections
YesPast
Sexual dysfunction
YesPast
Sexually transmitted diseases
YesPast
Other:
YesPast
Endocrine/Metabolic
Diabetes
YesPast
Hypothyroidism (low thyroid)
YesPast
Hyperthyroidism (overactive thyroid)
YesPast
Polycystic Ovarian Syndrome
YesPast
Infertility
YesPast
Metabolic syndrome/insulin resistance
YesPast
Eating disorder
YesPast
Hypoglycemia
YesPast
Other:
YesPast
Inflammatory/Immune
Rheumatoid arthritis
YesPast
Chronic fatigue syndrome
YesPast
Food allergies
YesPast
Environmental allergies
YesPast
Multiple chemical sensitivities
YesPast
Autoimmune disease
YesPast
Immune deficiency
YesPast
Mononucleosis
YesPast
Hepatitis
YesPast
Other:
YesPast
Musculoskeletal
Fibromyalgia
YesPast
Osteoarthritis
YesPast
Chronic pain
YesPast
Other:
YesPast
Skin
Eczema
YesPast
Psoriasis
YesPast
Acne
YesPast
Skin cancer
YesPast
Other:
YesPast
Cardiovascular
Angina
YesPast
Heart attack
YesPast
Heart failure
YesPast
Hypertension (high blood pressure)
YesPast
Stroke
YesPast
High blood fats (cholesterol, triglycerides)
YesPast
Rheumatic fever
YesPast
Arrythmia (irregular heart rate)
YesPast
Murmur
YesPast
Mitral valve prolapse
YesPast
Other:
YesPast
Neurologic/Emotional
Epilepsy/Seizures
YesPast
ADD/ADHD
YesPast
Headaches
YesPast
Migraines
YesPast
Depression
YesPast
Anxiety
YesPast
Autism
YesPast
Multiple sclerosis
YesPast
Parkinson’s disease
YesPast
Dementia
YesPast
Other:
YesPast
Cancer
Lung
YesPast
Breast
YesPast
Colon
YesPast
Ovarian
YesPast
Skin
YesPast
Other:
YesPast
Diagnostic Studies
Date
Comments
Bone density
Not Set
CT scan
Not Set
Colonoscopy
Not Set
Cardiac stress test
Not Set
EKG
Not Set
MRI
Not Set
Upper endoscopy
Not Set
Upper GI series
Not Set
Chest X-ray
Not Set
Other X-rays
Not Set
Barium enema
Not Set
Other:
Not Set
Injuries
Date
Comments
Broken bone(s)
Not Set
Back injury
Not Set
Neck injury
Not Set
Head injury
Not Set
Other:
Not Set
Surgeries
Date
Comments
Appendectomy
Not Set
Dental
Not Set
Gallbladder
Not Set
Hernia
Not Set
Hysterectomy
Not Set
Tonsillectomy
Not Set
Joint replacement
Not Set
Heart surgery
Not Set
Other:
Not Set
Hospitalizations
Date
Reason
Not Set
Not Set
Not Set
Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
General
Cold hands and feet
MildModerateSevere
Cold intolerance
MildModerateSevere
Daytime sleepiness
MildModerateSevere
Difficulty falling asleep
MildModerateSevere
Early waking
MildModerateSevere
Fatigue
MildModerateSevere
Fever
MildModerateSevere
Flushing
MildModerateSevere
Heat intolerance
MildModerateSevere
Night waking
MildModerateSevere
Nightmares
MildModerateSevere
Can’t remember dreams
MildModerateSevere
Low body temperature
MildModerateSevere
Head, Eyes, and Ears
Conjunctivitis
MildModerateSevere
Distorted sense of smell
MildModerateSevere
Distorted taste
MildModerateSevere
Ear fullness
MildModerateSevere
Ear ringing/buzzing
MildModerateSevere
Eye crusting
MildModerateSevere
Eye pain
MildModerateSevere
Eyelid margin redness
MildModerateSevere
Headache
MildModerateSevere
Hearing loss
MildModerateSevere
Hearing problems
MildModerateSevere
Migraine
MildModerateSevere
Sensitivity to loud noises
MildModerateSevere
Vision problems
MildModerateSevere
Musculoskeletal
Back muscle spasm
MildModerateSevere
Calf cramps
MildModerateSevere
Chest tightness
MildModerateSevere
Foot cramps
MildModerateSevere
Joint deformity
MildModerateSevere
Joint pain
MildModerateSevere
Joint redness
MildModerateSevere
Joint stiffness
MildModerateSevere
Muscle pain
MildModerateSevere
Muscle spasms
MildModerateSevere
Muscle stiffness
MildModerateSevere
Muscle twitches:
MildModerateSevere
Around eyes
MildModerateSevere
Arms or legs
MildModerateSevere
Muscle weakness
MildModerateSevere
Neck muscle spasm
MildModerateSevere
Tendonitis
MildModerateSevere
Tension headache
MildModerateSevere
TMJ problems
MildModerateSevere
Digestion
Anal spasms
MildModerateSevere
Bad teeth
MildModerateSevere
Bleeding gums
MildModerateSevere
Bloating of:
MildModerateSevere
Lower abdomen
MildModerateSevere
Whole abdomen
MildModerateSevere
Bloating after meals
MildModerateSevere
Blood in stools
MildModerateSevere
Burping
MildModerateSevere
Canker sores
MildModerateSevere
Cold sores
MildModerateSevere
Constipation
MildModerateSevere
Cracking at corner of lips
MildModerateSevere
Dentures w/poor chewing
MildModerateSevere
Diarrhea
MildModerateSevere
Difficulty swallowing
MildModerateSevere
Dry mouth
MildModerateSevere
Farting
MildModerateSevere
Fissures
MildModerateSevere
Foods "repeat" (reflux)
MildModerateSevere
Heartburn
MildModerateSevere
Hemorrhoids
MildModerateSevere
Intolerance to:
MildModerateSevere
Lactose
MildModerateSevere
All dairy products
MildModerateSevere
Gluten (wheat)
MildModerateSevere
Corn
MildModerateSevere
Eggs
MildModerateSevere
Fatty foods
MildModerateSevere
Yeast
MildModerateSevere
Liver disease/jaundice
MildModerateSevere
(yellow eyes or skin)
Lower abdominal pain
MildModerateSevere
Mucus in stools
MildModerateSevere
Nausea
MildModerateSevere
Periodontal disease
MildModerateSevere
Sore tongue
MildModerateSevere
Strong stool odor
MildModerateSevere
Undigested food in stools
MildModerateSevere
Upper abdominal pain
MildModerateSevere
Vomiting
MildModerateSevere
Lymph Nodes
Enlarged/neck
MildModerateSevere
Tender/neck
MildModerateSevere
Other enlarged/tender lymph nodes
MildModerateSevere
Skin, Dryness of
Eyes
MildModerateSevere
Feet
MildModerateSevere
Any cracking?
MildModerateSevere
Any peeling?
MildModerateSevere
Hair
MildModerateSevere
And unmanageable?
MildModerateSevere
Hands
MildModerateSevere
Any cracking?
MildModerateSevere
Any peeling?
MildModerateSevere
Mouth/throat
MildModerateSevere
Scalp
MildModerateSevere
Any dandruff?
MildModerateSevere
Skin in general
MildModerateSevere
Skin Problems
Acne on back
MildModerateSevere
Acne on chest
MildModerateSevere
Acne on face
MildModerateSevere
Acne on shoulders
MildModerateSevere
Athlete’s foot
MildModerateSevere
Bumps on back of upper arms
MildModerateSevere
Cellulite
MildModerateSevere
Dark circles under eyes
MildModerateSevere
Ears get red
MildModerateSevere
Easy bruising
MildModerateSevere
Eczema
MildModerateSevere
Herpes – genital
MildModerateSevere
Hives
MildModerateSevere
Jock itch
MildModerateSevere
Lackluster skin
MildModerateSevere
Moles w color/size change
MildModerateSevere
Oily skin
MildModerateSevere
Pale skin
MildModerateSevere
Patchy dullness
MildModerateSevere
Psoriasis
MildModerateSevere
Rash
MildModerateSevere
Red face
MildModerateSevere
Sensitive to bites
MildModerateSevere
Sensitive to poison ivy/oak
MildModerateSevere
Shingles
MildModerateSevere
Skin cancer
MildModerateSevere
Skin darkening
MildModerateSevere
Strong body odor
MildModerateSevere
Thick calluses
MildModerateSevere
Vitiligo
MildModerateSevere
Mood/Nerves
Agoraphobia
MildModerateSevere
Anxiety
MildModerateSevere
Auditory hallucinations
MildModerateSevere
Blackouts
MildModerateSevere
Depression
MildModerateSevere
Difficulty:
MildModerateSevere
Concentrating
MildModerateSevere
With balance
MildModerateSevere
With thinking
MildModerateSevere
With judgment
MildModerateSevere
With speech
MildModerateSevere
With memory
MildModerateSevere
Dizziness (spinning)
MildModerateSevere
Fainting
MildModerateSevere
Fearfulness
MildModerateSevere
Irritability
MildModerateSevere
Light-headedness
MildModerateSevere
Numbness
MildModerateSevere
Other phobias
MildModerateSevere
Panic attacks
MildModerateSevere
Paranoia
MildModerateSevere
Seizures
MildModerateSevere
Suicidal thoughts
MildModerateSevere
Tingling
MildModerateSevere
Tremor/trembling
MildModerateSevere
Visual hallucinations
MildModerateSevere
Cardiovascular
Angina/chest pain
MildModerateSevere
Breathlessness
MildModerateSevere
Heart attack
MildModerateSevere
Heart murmur
MildModerateSevere
High blood pressure
MildModerateSevere
Irregular pulse
MildModerateSevere
Mitral valve prolapse
MildModerateSevere
Palpitations
MildModerateSevere
Phlebitis
MildModerateSevere
Swollen ankles/feet
MildModerateSevere
Varicose veins
MildModerateSevere
Urinary
Bed wetting
MildModerateSevere
Hesitancy
MildModerateSevere
Infection
MildModerateSevere
Kidney disease
MildModerateSevere
Kidney stone
MildModerateSevere
Leaking/incontinence
MildModerateSevere
Pain/burning
MildModerateSevere
Urgency
MildModerateSevere
Eating
Binge eating
MildModerateSevere
Bulimia
MildModerateSevere
Can't gain weight
MildModerateSevere
Can't lose weight
MildModerateSevere
Carbohydrate craving
MildModerateSevere
Carbohydrate intolerance
MildModerateSevere
Poor appetite
MildModerateSevere
Salt cravings
MildModerateSevere
Frequent dieting
MildModerateSevere
Sweet cravings
MildModerateSevere
Caffeine dependency
MildModerateSevere
Respiratory
Bad breath
MildModerateSevere
Bad odor in nose
MildModerateSevere
Cough – dry
MildModerateSevere
Cough – productive
MildModerateSevere
Hayfever:
MildModerateSevere
Spring
MildModerateSevere
Summer
MildModerateSevere
Fall
MildModerateSevere
Change of season
MildModerateSevere
Hoarseness
MildModerateSevere
Nasal stuffiness
MildModerateSevere
Nose bleeds
MildModerateSevere
Post nasal drip
MildModerateSevere
Sinus fullness
MildModerateSevere
Sinus infection
MildModerateSevere
Snoring
MildModerateSevere
Sore throat
MildModerateSevere
Wheezing
MildModerateSevere
nw_radio
MildModerateSevere
Nails
Bitten
MildModerateSevere
Brittle
MildModerateSevere
Curve up
MildModerateSevere
Frayed
MildModerateSevere
Fungus – fingers
MildModerateSevere
Fungus – toes
MildModerateSevere
Pitting
MildModerateSevere
Ragged cuticles
MildModerateSevere
Ridges
MildModerateSevere
Soft
MildModerateSevere
Thickening of:
MildModerateSevere
Finger nails
MildModerateSevere
Toenails
MildModerateSevere
White spots/lines
MildModerateSevere
Itching Skin
Anus
MildModerateSevere
Arms
MildModerateSevere
Ear canals
MildModerateSevere
Eyes
MildModerateSevere
Feet
MildModerateSevere
Hands
MildModerateSevere
Legs
MildModerateSevere
Nipples
MildModerateSevere
Nose
MildModerateSevere
Genitals
MildModerateSevere
Roof of mouth
MildModerateSevere
Scalp
MildModerateSevere
Skin in general
MildModerateSevere
Throat
MildModerateSevere
Female Reproductive
Breast cysts
MildModerateSevere
Breast lumps
MildModerateSevere
Breast tenderness
MildModerateSevere
Ovarian cyst
MildModerateSevere
Poor libido (sex drive)
MildModerateSevere
Endometriosis
MildModerateSevere
Fibroids
MildModerateSevere
Infertility
MildModerateSevere
Vaginal discharge
MildModerateSevere
Vaginal odor
MildModerateSevere
Vaginal itch
MildModerateSevere
Vaginal pain
MildModerateSevere
Premenstrual:
MildModerateSevere
Bloating
MildModerateSevere
Breast tenderness
MildModerateSevere
Carbohydrate craving
MildModerateSevere
Chocolate craving
MildModerateSevere
Constipation
MildModerateSevere
Decreased sleep
MildModerateSevere
Diarrhea
MildModerateSevere
Fatigue
MildModerateSevere
Increased sleep
MildModerateSevere
Irritability
MildModerateSevere
Menstrual:
MildModerateSevere
Cramps
MildModerateSevere
Heavy periods
MildModerateSevere
Irregular periods
MildModerateSevere
No periods
MildModerateSevere
Scanty periods
MildModerateSevere
Spotting between
MildModerateSevere
Medications/Supplements
Current medications (include prescription and over-the-counter)
Medication
Dosage
Start Date (mo/yr)
Reason for Use
Not Set
Not Set
Not Set
Not Set
Not Set
Nutritional supplements (vitamins/minerals/herbs etc.)
Name and Brand
Dosage
Start Date (mo/yr)
Reason for Use
Not Set
Not Set
Not Set
Not Set
Not Set
Have medications or supplements ever caused unusual side effects or problems?
YesNo
If yes, describe:
Have you used any of these regularly or for a long time:
NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin?
YesNo
Tylenol (acetaminophen)?
YesNo
Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?
YesNo
How many times have you taken antibiotics?
Name
< 5
> 5
Reason for Use
Infancy/Childhood
Teen
Adulthood
Have you ever taken long term antibiotics?
YesNo
If yes, explain:
How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
Name
< 5
> 5
Reason for Use
Infancy/Childhood
Teen
Adulthood
Readiness Assessment and Health Goals
Readiness Assessment
Rate on a scale of 5 (very willing) to 1 (not willing):
In order to improve your health, how willing are you to:
Significantly modify your diet
54321
Take several nutritional supplements each day
54321
Keep a record of everything you eat each day
54321
Modify your lifestyle (e.g., work demands, sleep habits)
54321
Practice a relaxation technique
54321
Engage in regular exercise
54321
Rate on a scale of 5 (very confident) to 1 (not confident at all):
How confident are you of your ability to organize and follow through on the above health-related activities?
54321
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?
Rate on a scale of 5 (very supportive) to 1 (very unsupportive):
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
54321
Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):
How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program?
54321
Comments
Health Goals
What do you hope to achieve in your visit with us?
When was the last time you felt well?
Did something trigger your change in health?
What makes you feel better?
What makes you feel worse?
How does your condition affect you?
What do you think is happening and why?
What do you feel needs to happen for you to get better?
icon-facebookicon--twittericon-youtubeicon-rssicon-likeinicon-google