Health Assessment - Male
Email
example@example.com
Today's Date
/
Month
/
Day
Year
Date
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Phone number
10-digit
Address
Address 1
Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Genetic Background
African American
Hispanic
Mediterranean
Asian
Native American
Caucasian
Northern European
Other
When, Where, and From Whom did you last receive medical or health care?
*
Emergency Contact
First Name
Last Name
Emergency Contact Phone
10-digit
Releationship
Please select
Spouse
Parent
Sibling
Child
Grandparent
Friend
Aunt
Uncle
Cousin
Other
How did you hear about our practice?
Please select
Clinic website
IFM website
Referral from doctor
Referral from friend/family
Social media
Are you interested in weight loss?
Yes
No
How much weight do you think you need to lose?
5 lbs
10 lbs
15 lbs
20 lbs
25 lbs
30 lbs
35 lbs
40 lbs
45 lbs
50 lbs
55 lbs
60 lbs
65 lbs
70 lbs
75 lbs
greater than 75 lbs
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Current Health Concerns
Please rank current and ongoing health concerns in order of priority
*
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Allergies
Please list the Name of Medication/Supplement/Food and the Reaction
Allergies
*
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Lifestyle Review
Sleep
How many hours of sleep do you get each night on average?
Please select
less than 5 hours
5 hours
5.5 hours
6 hours
6.5 hours
7 hours
7.5 hours
8 hours
8.5 hours
9 hours
9.5 hours
10 hours
greater than 10 hours
Sleep
Yes or No
Do you have problems falling asleep?
Yes
No
Do you have problems staying asleep?
Yes
No
Do you have problems with insomnia
?
Yes
No
Do you feel rested upon awakening?
Yes
No
Do you have trouble waking up in the morning?
Yes
No
Do you snore?
Yes
No
Are your sleep habits routine?
Yes
No
Describe how you fall asleep?
Do you use sleeping aids?
Yes
No
Please explain sleeping aid use
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Lifestyle Review
Exercise
Current exercise program
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?
Yes
A little
No
Are there any problems that limit exercise?
Yes
No
If yes, please explain
Do you feel unusually fatigued or sore after exercise?
Yes
No
If yes, please explain
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Lifestyle Review
Nutrition
Do you currently follow any of the following special diets or nutritional programs? (check all that apply)
Vegetarian
Vegan
Allergy
Elimination
Low fat
Low carb
High protein
Blood type
Low sodium
No dairy
No wheat
Gluten free
Paleo
Keto
Other
Do you have sensitivities to certain foods?
Yes
No
Please list food sensitivities here:
*
Do you have an aversion to certain foods?
Yes
No
If yes, please explain
Do you adversely react to: (check all that apply)
Monosodium Glutamate (MSG)
Artificial sweeteners
Garlic / onion
Cheese
Citrus foods
Chocolate
Alcohol
Sulfite containing foods (wine, salad bars, dried fruit)
Preservatives
Food colorings
Other
Are there any foods that you crave or binge on?
Yes
No
If yes, list foods:
Do you eat 3 meals per day?
Yes
No
If no, how many?
1
2
4
5
6
7
More than 7
Does skipping a meal greatly affect you?
Yes
No
How many meals do you eat out per week?
0-1
1-3
3-5
>5 times per week
Check the factors that apply to your current lifestyle and eating habits:
Fast eater
Significant other or family members have special dietary needs
Eat too much
Love to eat
Late-night eating
Eat because I have to
Dislike healthy foods
Have a negative relationship with food
Time constraints
Struggle with eating issues
Travel frequently
Emotional eater (eat when sad, lonely, bored, etc.)
Healthy foods not readily available
Eat too much under stress
Poor snack choices
Eat too little under stress
Significant other or family members don't like healthy foods
Don't care to cook
Confused about nutrition advice
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Lifestyle Review
Weight History
Your present weight
in pounds
Your weight 1 year ago
in pounds
Your weight 5 years ago
in pounds
Your MAXIMUM adult weight
in pounds
Date of MAXIMUM adult weight
-
Month
-
Day
Year
Date
Your MINIMUM adult weight
in pounds
Date of MINIMUM adult weight
-
Month
-
Day
Year
Date
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Lifestyle Review
Diet
Please record what you eat in a typical day:
Typical Foods Eaten
Breakfast
Lunch
Dinner
Snacks
Fluids
How many servings do you eat in a typical week of these foods?
# of Servings per week
Fruits (not juice)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Vegetables (not including white potatoes)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Legumes (beans, peas, etc)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Red meat
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Fish
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Dairy
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Dairy Alternatives
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Nuts & Seeds
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Fats & Oils
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Cans of soda (reg or diet)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Sweets (candy, cookies, cake, etc.)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15
Do you drink caffeinated beverages?
Yes
No
If yes, select amounts per day:
Amount per day
Coffee (cups)
1
2
3
4
>4
Tea (cups)
1
2
3
4
>4
Caffeinated sodas - reg or diet (cans)
1
2
3
4
>4
Do you have adverse reactions to caffeine?
Yes
No
If yes, explain:
When I drink caffeine I feel:
Normal
Irritable or wired
Aches or pains
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Lifestyle review
Smoking
Do you smoke?
Yes
Previous smoker, but not currently
No
If current smoker, please complete
*
Have you attempted to quit?
Yes
No
If yes, using what methods?
If previous smoker, please complete
*
Are you regularly exposed to second-hand smoke?
Yes
No
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Lifestyle Review
Alcohol
How many alcoholic beverages do you drink in a week?
None
1-3
4-6
7-10
>10
1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits
Previous alcohol intake?
Yes
None
Previous alcohol amount
Mild
Moderate
High
Have you ever had a problem with alcohol?
Yes
No
Details regarding alcohol problem:
*
Have you ever thought about getting help to control or stop your drinking?
Yes
No
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Lifestyle Review
Other Substances
Are you currently using any recreational drugs?
Yes
No
If yes, explain:
Tyoe of recreational drugs used
Have you ever used inhaled or IV recreational drugs
Yes
No
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Lifestyle Review
Stress
Do you feel you have an excessive amount of stress in your life?
Yes
No
Do you feel you can easily handle the stress in your life?
Yes
No
How much stress do each of the following cause on a daily basis?
1=Lowest, 10=Highest
Work
1 - Lowest
2
3
4
5
6
7
8
9
10 - Highest
Family
1 - Lowest
2
3
4
5
6
7
8
9
10 - Highest
Social
1 - Lowest
2
3
4
5
6
7
8
9
10 - Highest
Finances
1 - Lowest
2
3
4
5
6
7
8
9
10 - Highest
Health
1 - Lowest
2
3
4
5
6
7
8
9
10 - Highest
Check any of the following that create stress for you at work or home
Chemicals
Pollution
Exhaust
Poor Air Ventilation
Lighting
Lack of Sunshine
Lunar Cycles
High Humidity
Dampness
Season Change
Spring
Summer
Fall
Winter
Cold
Heat
Noise
Deadlines
Pressure to perform
Relationship with Co-workers
Relationship with household members
Other
Do you adapt well to change?
Yes
No
Do you use relaxation techniques?
Yes
No
If yes, how often?
Which techniques do you use? (check all that apply)
Meditation
Breathing
Tai Chi
Yoga
Prayer
Other
Have you ever sought counseling?
Yes
No
Are you currently in therapy?
Yes
No
If yes, describe:
Therapy description
Have you ever been abused, a victim of crime, or experienced a significant trauma?
Yes
No
What are your hobbies or leisure activities?
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Lifestyle Review
Relationships
Marital Status (check all that apply)
Single
Married
Divorced
Gay/Lesbian
Long-term Partner
Widow/er
With whom do you live? (include children, parents, relatives, friends, pets)
Current occupation
Previous occupation
Who are the most important people in your life?
*
Please check all of your resources for emotional support: (check all that apply)
Spouse/Partner
Family
Friends
Religious/Spiritual
Pets
None
Other
Do you have a religious or spiritual practice
Yes
No
If yes, what kind?
How well have things been going for you? (Mark on a scale of 1-10, or N/A if not applicable)
Mark on scale 1-10 or N/A
Overall
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
At school
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
In your job
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
In your social life
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With close friends
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With sex
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With your attitude
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With your boyfriend/girlfriend
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With you children
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With your parents
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
With your spouse
N/A
1-Poorly
2
3
4
5-Fine
6
7
8
9
10-Very Well
Describe your marriage(s) or long-term relationships:
Describe your divorce(s) or separations:
Describe your present relationship:
Indicate which of the following words or phrases best describe these people:
Phrase that best describes
Father
0 - Not Applicable
1 - Warm & affectionate
2 - Trusting
3 - Perfectionist & driven
4 - Selfish
5 - Selfless & always doing for others
6 - Insecure
7 - Fearful & anxious, distrustful
8 - Irate & angry
9 - Self-reliant
10 - Hungry for approval & recognition
11 - Needing to be with people
12 - Uncomfortable with intimacy
13 - Very concerned about personal health and well-being
Mother
0 - Not Applicable
1 - Warm & affectionate
2 - Trusting
3 - Perfectionist & driven
4 - Selfish
5 - Selfless & always doing for others
6 - Insecure
7 - Fearful & anxious, distrustful
8 - Irate & angry
9 - Self-reliant
10 - Hungry for approval & recognition
11 - Needing to be with people
12 - Uncomfortable with intimacy
13 - Very concerned about personal health and well-being
Other (guardian)
0 - Not Applicable
1 - Warm & affectionate
2 - Trusting
3 - Perfectionist & driven
4 - Selfish
5 - Selfless & always doing for others
6 - Insecure
7 - Fearful & anxious, distrustful
8 - Irate & angry
9 - Self-reliant
10 - Hungry for approval & recognition
11 - Needing to be with people
12 - Uncomfortable with intimacy
13 - Very concerned about personal health and well-being
Spouse / Partner
0 - Not Applicable
1 - Warm & affectionate
2 - Trusting
3 - Perfectionist & driven
4 - Selfish
5 - Selfless & always doing for others
6 - Insecure
7 - Fearful & anxious, distrustful
8 - Irate & angry
9 - Self-reliant
10 - Hungry for approval & recognition
11 - Needing to be with people
12 - Uncomfortable with intimacy
13 - Very concerned about personal health and well-being
You
0 - Not Applicable
1 - Warm & affectionate
2 - Trusting
3 - Perfectionist & driven
4 - Selfish
5 - Selfless & always doing for others
6 - Insecure
7 - Fearful & anxious, distrustful
8 - Irate & angry
9 - Self-reliant
10 - Hungry for approval & recognition
11 - Needing to be with people
12 - Uncomfortable with intimacy
13 - Very concerned about personal health and well-being
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History
Patient's Birth / Childhood History
You were born:
Please select
Term
Premature
Don't know
Were there any pregnancy or birth complications?
Yes
No
If yes, explain
Explain birth complications
You were:
Breast-fed
Bottle-fed
Don't know
If breast-fed, how long?
Please select
< 1 month
1 month
1-3 months
4-6 months
7-11 months
1 year
1.5 years
2 years
> 2 years
If bottle-fed, describe type of formula:
Formula
Age of introduction of:
Age
Solid Food
Don't know
3 years
Wheat
Don't know
3 years
Dairy
Don't know
3 years
As a child, were there any foods that you avoided because they gave you symptoms?
Yes
No
If yes, what foods and what symptoms?
*
Did you eat a lot of sugar or candy as a child?
Yes
No
How many children are in the family in which you were raised?
1
2
3
4
5
6
7
8
9
>9
Where do you fit in the birth order?
Mark the box next to the words that describe your childhood
Happy
Good
Fair
Unhappy
Teriibly depressing
Verbally abusive
Physically abusive
Other
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History
Bowel Movements
How often do you have a bowel movement?
Several times per day
Once per day
Every other day
Every three days
Once per week
Less than once per week
Other
What is the average consistency of the stool?
Please select
Watery, diarrhea
Pudding-like
Soft, snake-like
Larger, log like
Rock-like
Does your stool often float?
Yes
No
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History
Dental
Indicate if you have any of the following, and provide number if applicable
Number
Silver mercury fillings
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Gold fillings
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Root canals
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Implants
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Caps/Crowns
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Tooth pain
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Bleeding gums
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Gingivitis
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Problems with chewing
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Other
Don't have
1
2
3
4
5
6
7
8
9
10
>10
Have you had any mercury fillings removed?
Yes
No
Please list the date(s) the mercury fillings were removed:
*
How many fillings did you have as a kid?
Please select
None
1
2
3
4
5
6
7
8
9
10
>10
Do you brush regularly?
Yes
No
How long do you spend brushing each time?
Please select
2 min
Do you floss regularly?
Yes
No
How often do you floss?
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History
Environmental / Detoxification
Do any of these significantly affect you?
Cigarette smoke
Perfume/colognes
Auto exhaust fumes
Other
In your work or home environment are you regularly exposed to: (check all that apply)
Mold
Water leaks
Renovations
Chemicals
Electromagnetic radiation
Damp environments
Carpets or rugs
Old paint
Stagnant or stuffy air
Smokers
Pesticides
Herbicides
Harsh chemicals (solvents, glues, gas, acids, etc.)
Cleaning chemicals
Heavy metals (lead, mercury, etc.)
Paints
Airplane travel
Other
Have you had a significant exposure to any harmful chemicals?
Yes
No
If yes, please list chemical name, length of exposure, and date:
*
Have you ever had a job where you were exposed to chemicals or fumes.
Yes
No
If yes, please describe
Do you have any pets or farm animals?
Yes
No
If yes, do they live:
Inside
Outside
Both Inside & Outside
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History
Men's
Check box if applicable
Testicular mass
Testicular pain
Prostate enlargement
Prostate infection
Change in sex drive
Impotence
Premature ejaculation
Difficulty obtaining an erection
Difficulty maintaining an erection
Loss of control of urine
Urinary urgency/hesitancy/change in stream
Vasectomy
Nocturia (urination at night)
Sexually transmitted diseases
# times you urinate per night
Please select
1
2
3
>3
Yes to Nocturia
Please describe sexually transmitted disease(s)
Yes to STD
Have you had a PSA test?
Yes
No
Last PSA test
-
Month
-
Day
Year
Date
What was your PSA level?
Please select
0-2
2-4
4-10
>10
Yes to PSA test
Other tests/procedures (list type and dates)
*
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History
Family History
Check family members that have/had any of the following:
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune disease
Arthritis
Kidney disease
Thyroid problems
Seizures/epilepsy
Psychiatric disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable Bowel Syndrome
Dementia
Sustance abuse
Genetic disorders
Check family members that have/had any of the following:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune disease
Arthritis
Kidney disease
Thyroid problems
Seizures/epilepsy
Psychiatric disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable Bowel Syndrome
Dementia
Sustance abuse
Genetic disorders
Please indicate Age (if still alive), Age of death (if deceased)
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Age (if still alive)
Age of death (if deceased)
Please indicate Age (if still alive), Age of death (if deceased)
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Age (if still alive)
Age of death (if deceased)
If 'Other' in the tables above, please describe:
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History
Medical History
Gastrointestinal
Current
Past
Never
Irritable bowel syndrome
GERD (reflux)
Chron's disease / ulcerative colitis
Peptic ulcer disease
Celiac disease
Gallstones
Other
If Gastrointestinal 'Other' - please describe:
Respiratory
Current
Past
Never
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep apnea
Other
If Respiratory 'Other' - please describe:
Urinary / Genital
Current
Past
Never
Kidney stones
Gout
Interstitial cystitis
Frequent yeast infections
Frequent urinary tract infections
Sexual dysfunction
Sexually transmitted diseases
Other
If Urinary/Genital 'Other' - please describe:
Endocrine / Metabolic
Current
Past
Never
Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Infertility
Metabolic syndrome / insulin resistance
Eating disorder
Hypoglycemia
Other
If Endocrine / Metabolic 'Other' - please describe:
Inflammatory / Immune
Current
Past
Never
Rheumatoid arthritis
Chronic fatigue syndrome
Food allergies
Environmental allergies
Multiple chemical sensitivities
Autoimmune disease
Immune deficiency
Mononucleosis
Hepatitis
Other
If Inflammatory / Immune 'Other' - please describe:
Musculoskeletal
Current
Past
Never
Fibromyalgia
Osteoarthritis
Chronic pain
Other
If Musculoskeletal 'Other' - please describe:
Skin
Current
Past
Never
Eczema
Psoriasis
Acne
Skin cancer
Other
If Skin 'Other' - please describe:
Cardiovascular
Current
Past
Never
Angina
Heart attack
Heart failure
Hypertension (high blood pressure)
Stroke
High blood fats (cholesterol, triglycerides)
Rheumatic fever
Arrythmia (irregular heart rate)
Murmur
Mitral valve prolapse
Other
If Cardiovascular 'Other' - please describe:
Neurologic / Emotional
Current
Past
Never
Epilepsy / Seizures
ADD / ADHD
Headaches
Migraines
Depression
Anxiety
Autism
Multiple sclerosis
Murmur
Mitral valve prolapse
Other
If Neurologic / Emotional 'Other' - please describe:
Cancer
Current
Past
Never
Lung
Breast
Colon
Prostate
Skin
Other
If Cancer 'Other' - please describe:
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History
Medical History (continued)
Medical History - Diagnostic Studies
*
Medical History - Injuries
*
Medical History - Surgeries
*
Hospitalizations
*
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Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
General
Mild
Moderate
Severe
Cold hands and feet
Cold Intolerance
Daytime sleepiness
Difficulty falling asleep
Early waking
Fatigue
Fever
Flushing
Heat intolerance
Night waking
Nightmares
Can't remember dreams
Low body temperature
Head, Eyes, and Ears
Mild
Moderate
Severe
Conjuctivitis
Distorted sense of smell
Distorted taste
Ear fullness
Ear ringing/buzzing
Eye crusting
Eye pain
Eyelid margin redness
Headache
Hearing loss
Hearing problems
Migraine
Sensitivity to loud noises
Vision problems
Musculoskeletal
Mild
Moderate
Severe
Back muscle spasm
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint pain
Joint redness
Joint stiffness
Muscle pain
Muscle spasms
Muscle stiffness
Muscle twitches:
----Around eyes
----Arms or legs
Muscle weakness
Neck muscle spasm
Tendonitis
Tension Headache
TMJ problems
Mood / Nerves
Mild
Moderate
Severe
Agoraphobia
Anxiety
Auditory hallucinations
Blackouts
Depression
Difficulty:
----Concentrating
----With balance
----With thinking
----With judgement
----With speech
----With memory
Dizziness (spinning)
Fainting
Fearfulness
Irritability
Light-headedness
Numbness
Other phobias
Panic attacks
Paranoia
Seizures
Suicidal thoughts
Tingling
Tremor/trembling
Visual hallucinations
Cardiovascular
Mild
Moderate
Severe
Angina / chest pain
Breathlessness
Heart attack
Heart murmur
High blood pressure
Irregular pulse
Mitral valve prolapse
Palpitations
Phlebitis
Swollen ankles/feet
Varicose veins
Urinary
Mild
Moderate
Severe
Bed wetting
Hesitancy
Infection
Kidney disease
Kidney stone
Leaking/incontinence
Pain/burning
Prostate enlargement
Prostate infection
Urgency
Digestion
Mild
Moderate
Severe
Anal spasms
Bad teeth
Bleeding gums
Bloating of:
----Lower abdomen
----Whole abdomen
----Bloating after meals
Blood in stools
Burping
Canker sores
Cold sores
Constipation
Cracking at corner of lips
Dentures w/poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Flatulence (passing gas)
Fissures
Foods "repeat" (reflux)
Heartburn
Hemorrhoids
Intolerance to:
----Lactose
----All dairy products
----Gluten (wheat)
----Corn
----Eggs
----Fatty foods
----Yeast
Liver disease/jaundice
(yellow eyes or skin)
Lower abdominal pain
Mucus in stools
Nausea
Periodontal disease
Sore tongue
Strong stool odor
Undigested food in stools
Upper abdominal pain
Vomiting
Eating
Mild
Moderate
Severe
Binge eating
Bulimia
Can't gain weight
Can't lose weight
Carbohydrate craving
Carbohydrate intolerance
Poor appetite
Salt cravings
Frequent dieting
Sweet cravings
Caffeine dependency
Respiratory
Mild
Moderate
Severe
Bad breath
Bad odor in nose
Cough - dry
Cough - productive
Hayfever:
----Spring
----Summer
----Fall
----Change of season
Hoarseness
Nasal stuffiness
Nose bleeds
Post nasal drip
Sinus fullness
Sinus infection
Snoring
Sore throat
Wheezing
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Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
Nails
Mild
Moderate
Severe
Bitten
Brittle
Curve up
Frayed
Fungus - fingers
Fungus - toes
Pitting
Ragged cuticles
Ridges
Soft
Thickening of:
----Finger nails
----Toenails
White spots/lines
Lymph Nodes
Mild
Moderate
Severe
Enlarged/neck
Tender/neck
Other enlarged/tender
lymph nodes
Skin, Dryness of
Mild
Moderate
Severe
Eyes
Feet
----Any cracking?
----Any peeling?
Hair
----And unmanageable?
Hands
----Any cracking?
----Any peeling?
Mouth/throat
Scalp
----Any dandruff?
Skin in general
Skin Problems
Mild
Moderate
Severe
Acne on back
Acne on chest
Acne on face
Acne on shoulders
Acne on scalp
Athlete's foot
Bumps on back
of upper arms
Cellulite
Dark circles under eyes
Ears get red
Easy bruising
Eczema
Herpes - genital
Hives
Jock itch
Lackluster skin
Moles w color/size change
Oily skin
Pale skin
Patchy dullness
Psoriasis
Rash
Red face
Sensitive to bites
Sensitive to poison ivy/oak
Shingles
Skin cancer
Skin darkening
Strong body odor
Thick calluses
Vitiligo
Itching Skin
Mild
Moderate
Severe
Anus
Arms
Ear canals
Eyes
Feet
Hands
Legs
Nipples
Nose
Genitals
Roof of mouth
Scalp
Skin in general
Throat
Male Reproductive
Mild
Moderate
Severe
Discharge from penis
Ejaculation problem
Genital pain
Impotence
Infection
Lumps in testicles
Poor libido (low sex drive)
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Medications / Supplements
Current medications (include prescription & over-the-counter)
*
Current supplements (vitamins/minerals/herbs etc.)
*
Have medications or supplements ever caused unusual side effects or problems?
Yes
No
If yes, describe:
Have you used any of these regularly or for a long time?
Regularly or long time?
NSAIDs (Advil, Motrin,
Aleve, etc.) or Aspirin
Yes
No
Tylenol (acetaminophen)
Yes
No
Acid-blocking drugs
(Zantac, Prilosec, Nexium, etc.)?
Yes
No
How many times have you taken antibiotics?
*
Have you ever taken long-term antibiotics?
Yes
No
If yes, explain:
How often have you taken oral steroids (e.g. cortisone, prednisone, etc.)?
*
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Readiness Assessment
In order to improve your health, how willing are you to:
Significantly modify your diet
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Take several nutritional supplements each day
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Keep a record of everything you eat each day
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Modify your lifestyle (e.g., work demands, sleep habits)
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Practice a relaxation technique
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
Engage in regular exercise
1
2
3
4
5
Not willing
Very willing
1 is Not willing, 5 is Very willing
How confident are you of your ability to organize and follow through on the above health-related activities?
1
2
3
4
5
Not confident at all
Very confident
1 is Not confident at all, 5 is Very confident
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
1
2
3
4
5
Very unsupportive
Very supportive
1 is Very unsupportive, 5 is Very supportive
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?
1
2
3
4
5
Very infrequent contact
Very frequent contact
1 is Very infrequent contact, 5 is Very frequent contact
Any additional comments about your readiness
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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?
Should be Empty: