Address: Age: DOB: Occupation: Referred by: Primary Reason for Visit: Other Concerns: Number of Children: Ages:

Transcription

1 Name: Date: Address: Home Phone: Cell Phone: E mail: Age: DOB: Occupation: Referred by: Height: Weight: Sex: M / F Primary Reason for Visit: Other Concerns: Single Married Divorced Widowed Number of Children: Ages: Do you smoke? Y / N How many cigarettes per day? Date quit / Do you drink alcohol? Y /N How many drinks per day? per week? Has alcohol ever been a problem for you? Y / N Do you use other drugs? Y / N Have you in the past? Y / N Caffeine: number of cups per day Type: Do you exercise? Y / N How often? Type: How important is religion/spirituality in your life? Not at all Somewhat Very

2 Past Medical History Problem/Diagnosis: Date: Previous Surgeries: Date: _ Diagnostic Studies: Date: Comments: Bone Scan CAT Scan Chest X- Ray Colonoscopy

3 Date: Comments: EKG Neck/Back X- Ray MRI Upper GI Series Barium Enema How often have you taken antibiotics? Infancy/childhood: less than 5 times greater than 5 times Teen: less than 5 times greater than 5 times Adulthood: less than 5 times greater than 5 times How often have you taken steroids? Infancy/childhood: less than 5 times greater than 5 times Teen: less than 5 times greater than 5 times Adulthood: less than 5 times greater than 5 times Are you allergic to any medications: Please list name and reaction Please list all the medications you are currently taking Name: Dosage: Date started:

4 Please list all vitamins, minerals, and supplements you are currently taking Name: Dosage: Date started: Were you a full- term baby? Y / N Were you breastfed? Y / N As a child, were there any foods you had to avoid because they gave you symptoms? Y / N List: Have you been diagnosed with any food allergies? Y / N (list) Are you on a special diet? Y / N Type: Do you crave certain foods? Y / N Do you have an aversion to certain foods? Y / N Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives? Y / N If yes, are the symptoms associated with any particular food? Do you have mercury amalgam fillings? Y / N Do you have any artificial joints or implants? Y / N Do you feel worse at certain times of the year? spring summer fall winter Are you exposed to toxic metals at work or home? Y / N Do odors bother you? Y / N What is the attitude of those close to you about your illness? supportive non- supportive

5 Describe your current stress level: Have you experienced any major losses in life? Have you been involved in abusive relationships in your life? Y / N Do you feel safe in your home? Y / N Have you lived or traveled outside of the U.S.? Y / N If yes, where? Please list everything you eat and drink for a full day Breakfast: Snack: Lunch: Snack: Dinner: Snack: Family History: Has anyone in your family had any major illnesses? (i.e. cancer, heart disease, high cholesterol, thyroid disease, diabetes, stroke, liver disease, depression, arthritis, Alzheimer s disease, high blood pressure, autoimmune disease) Mother: Father: Brothers: Sisters: Children: Grandparents: Others:

6 Women Only (men, please skip to next page) Have you ever been pregnant? Y / N # term births # preemies # miscarriages # abortions Birth weight of largest baby Did you develop toxemia/preeclampsia? Y / N Have you had issues with infertility? Y / N Age at first period: Date of last pap smear: Date of last mammogram: Any abnormalities? Have you ever used birth control pills? Y / N If yes, when? Did taking the pill agree with you? Y / N Do you currently use contraception? Y / N type: Date of last period: Are you in menopause? Y / N Symptoms: Mild Moderate Severe Bloating O O O Breast tenderness O O O Carbohydrate craving O O O Constipation O O O Decreased sleep O O O Diarrhea O O O Fatigue O O O Increased sleep O O O Irritability O O O Cramps O O O Heavy periods O O O Irregular periods O O O No periods O O O Scanty periods O O O Spotting between O O O

7 Please check if symptoms have occurred in the past 6 months: General: Mild Moderate Severe Cold hands/feet O O O Cold intolerance O O O Daytime sleepiness O O O Hard to fall asleep O O O Early waking O O O Fatigue O O O Fever O O O Flushing O O O Heat intolerance O O O Night waking O O O Nightmares O O O No dream recall O O O Head, Ears, Eyes: Distorted smell O O O Distorted taste O O O Ear fullness O O O Ear pain O O O Ear ringing O O O Eye crusting O O O Eye pain O O O Vision problems O O O Hearing problems O O O Headaches O O O Migraine O O O Musculoskeletal: Mild Moderate Severe Back muscle spasm O O O Calf cramps O O O Chest tightness O O O Foot cramps O O O Joint deformity O O O Joint pain O O O Joint stiffness O O O Muscle pain O O O Muscle twitches (eyes) O O O Muscle weakness O O O Neck muscle spasm O O O Tendonitis O O O TMJ problems O O O Mood/Nerves: Agoraphobia O O O Auditory hallucinations O O O Irritability O O O Depression O O O Difficulty with: Concentration O O O Balance O O O Judgment O O O Speech O O O Memory O O O Dizziness (spinning) O O O Light- headedness O O O

8 Mood/Nerves: Mild Moderate Severe Numbness O O O Other phobias O O O Panic attacks O O O Paranoia O O O Seizures O O O Suicidal thoughts O O O Tingling O O O Tremor O O O Visual hallucinations O O O Eating: Binge eating O O O Can t gain weight O O O Can t lose weight O O O Carbohydrate craving O O O Carb intolerance O O O Poor appetite O O O Salt craving O O O Digestion: Anal spasms O O O Bad teeth O O O Bleeding gums O O O Bloating O O O Blood in stools O O O Burping O O O Canker sores O O O Cold sores O O O Constipation O O O Digestion: Mild Moderate Severe Fissures O O O Heartburn O O O Hemorrhoids O O O Intolerance to: Milk O O O Gluten (wheat) O O O Eggs O O O Fatty foods O O O Yeast O O O Abdominal pain O O O Mucus in stools O O O Nausea O O O Sore tongue O O O Diarrhea O O O Difficulty swallowing O O O Dry mouth O O O Passing gas O O O Undigested food in stools O O O Vomiting O O O Skin Problems: Acne O O O Athlete s foot O O O Easy bruising O O O Cellulite O O O Bumps on upper arms O O O Eczema O O O

9 Skin: Mild Moderate Severe Herpes- genital O O O Hives O O O Jock Itch O O O Rash O O O Red face O O O Psoriasis O O O Shingles O O O Skin darkening O O O Skin itching O O O Where? Dry skin O O O Dry hair O O O Dry scalp O O O Lymph nodes Enlarged O O O Tender O O O Nails- brittle O O O fungus O O O Respiratory: Bad breath O O O Bad odor in nose O O O Dry cough O O O Productive cough O O O Hay fever- Spring O O O Summer O O O Respiratory: Mild Moderate Severe Sinus congestion O O O Nose bleeds O O O Post nasal drip O O O Snoring O O O Sore throat O O O Wheezing O O O Cardiovascular: Chest pain O O O Shortness of breath O O O Heart murmur O O O High blood pressure O O O Irregular pulse O O O Palpitations O O O Swollen ankles/feet O O O Varicose veins O O O Urinary: Infection O O O Incontinence O O O Kidney stone O O O Pain/burning O O O Men only: Discharge from penis O O O Ejaculation problems O O O Prostate problems O O O Poor libido O O O Fall O O O Hoarseness O O O Sign: Date: