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PATIENT CENTER
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IMUA Team
Dr. Elizabeth Ignacio, MD
Dr. Nicole Gesik, DO
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Step
1
of
18
5%
General Information
Name
Age
General Information
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Email
Address
City
State
Zip
Phone (Home)
(Cell)
(Work)
Genetic Background:
African
American
Hispanic
Mediterranean
Native American
Caucasian Northern European
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 website
IFM website
Social media
Referral from doctor
Referral from friend/family member
Other
Current Health Concerns
Please rank current and ongoing health concerns in order of priority
Describe Problem (Ex: Post Nasal Drip)
Severity
Mild (Yes/No)
Moderate (Yes/No)
Severe (Yes/No)
Prior Treatment/Approach
Excellent (Yes/No)
Good (Yes/No)
Fair (Yes/No)
Add
Remove
Allergies
Name of Medication/Supplement/Food:
Reaction:
Add
Remove
Lifestyle Review
Sleep
How many hours of sleep do you get each night on average?
Do you have problems falling asleep?
Yes
No
Staying asleep?
Yes
No
Do you have problems with insomnia?
Yes
No
Do you snore?
Yes
No
Do you feel rested upon awakening?
Yes
No
Do you use sleeping aids?
Yes
No
Explain:
Exercise
Current Exercise Program:
Activity
Type
# of Times Per Week
Time/Duration (Minutes)
Add
Remove
Do you feel motivated to exercise?
Yes
A little
No
Are there any problems that limit exercise?
Yes
No
Explain:
Do you feel unusually fatigued or sore after exercise?
Yes
No
Explain:
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
Other
Select All
Mention
Do you have sensitivities to certain foods?
Yes
No
List food and symptoms::
Do you have an aversion to certain foods?
Yes
No
Explain:
Do you adversely react to:
(Check all that apply)
Monosodium glutamate (MSG)
Artificial sweeteners
Garlic/onion
Cheese
Citrus foods
Chocolate
Alcohol
Red wine
Sulfite-containing foods (wine, dried fruit, salad bars)
Preservatives
Food colorings
Other food substances:
Mention
Are there any foods that you crave or binge on?
Yes
No
What foods?
Do you eat 3 meals a day?
Yes
No
How many
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 meals 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 needs Late-night eating
Love to eat
Dislike healthy foods
Eat because I have to
Time constraints
Have negative relationship to food Travel frequently
Struggle with eating issues
Eat more than 50% of meals away from home
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 Don't care to cook healthy foods
Confused 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?
Yes
No
Coffee (cups per day)
1
2-4
>4
Tea (cups per day)
1
2-4
>4
Caffeinated sodas—regular or diet (cans per day)
1
2-4
>4
Do you have adverse reactions to caffeine?
Yes
No
Explain
When you drink caffeine do you feel:
Irritable or wired
Aches or pains
Smoking
Do you smoke currently?
Yes
No
Packs per day:
Number of years
What type?
Cigarettes
Smokeless
Pipe
Cigar
E-Cig
Have you attempted to quit?
Yes
No
Using what methods:
If you smoked previously:
Packs per day:
Number of years
Are you regularly exposed to second-hand smoke?
Yes
No
Alcohol
How many alcoholic beverages do you drink in a week?
(1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)
1-3
4-6
7-10
>10
None
Previous alcohol intake?
Yes
None
Mild Moderate High
Mild
Moderate
High
Have you ever had a problem with alcohol?
Yes
No
When?
Explain the problem:
Have you ever thought about getting help to control or stop your drinking?
Yes
No
Other Substances
Are you currently using any recreational drugs?
Yes
No
Type:
Have you ever used IV or inhaled recreational drugs?
Yes
No
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
(Rate on scale of 1-10, 10 being highest)
Work
Family
Social
Finances
Health
Other
Do you use relaxation techniques?
Yes
No
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
Describe:
Have you ever been abused, a victim of crime, or experienced a significant trauma?
Yes
No
What are your hobbies or leisure activities?
Relationships
Marital status:
Single
Married
Divorced
Gay/Lesbian
Long-Term Partner
Widower
With whom do you live?
(Include children, parents, relatives, friends, pets)
Current occupation:
Previous occupations:
Do you have resources for emotional support?
Yes
No
Do you have resources for emotional support?
Spouse/Partner
Family
Friends
Religious/Spiritual
Pets
Other:
Mention
Do you have a religious or spiritual practice?
Yes
No
What kind?
How well have things been going for you?
(Mark on scale of 1-10, or N/A if not applicable)
(1-4=Poor, 5-9=Fine, 10=Very Well)
Overall
1
2
3
4
5
6
7
8
9
10
At school
1
2
3
4
5
6
7
8
9
10
In your job
1
2
3
4
5
6
7
8
9
10
In your social life
1
2
3
4
5
6
7
8
9
10
With close friends
1
2
3
4
5
6
7
8
9
10
With sex
1
2
3
4
5
6
7
8
9
10
With your attitude
1
2
3
4
5
6
7
8
9
10
With your boyfriend/girlfriend
1
2
3
4
5
6
7
8
9
10
With your children
1
2
3
4
5
6
7
8
9
10
With your parents
1
2
3
4
5
6
7
8
9
10
With your spouse
1
2
3
4
5
6
7
8
9
10
History
Patient's Birth/Childhood History:
You were born:
Term
Premature
Don't know
Were there any pregnancy or birth complications?
Yes
No
explain:
You were:
Breast-fed
Bottle-fed
Don't know
How long?
Type of formula:
Age of introduction of:
Solid food:
Wheat
Dairy
As a child, were there any foods that were avoided because they gave you symptoms? If yes, what foods and what symptoms?
Yes
No
What foods and what symptoms?
(Example: milk-gas and diarrhea)
Did you eat a lot of sugar or candy as a child?
Yes
No
Dental History:
Silver mercury fillings
Gold fillings
Root canals
Implants Caps/Crowns
Tooth pain
Bleeding gums
Gingivitis
Problems with chewing
Other dental concerns (explain)
Check if you have any of the following, and provide number if applicable:
Explain
Have you had any mercury fillings removed?
Yes
No
When?
How many fillings did you have as a kid?
Do you brush regularly?
Yes
No
Do you floss regularly?
Yes
No
Environmental/Detoxification History
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
Mention
Have you had a significant exposure to any harmful chemicals?
Yes
No
Chemical name
Length of exposure
Date:
MM slash DD slash YYYY
Do you have any pets or farm animals?
Yes
No
Do they live:
Inside
Outside
Both inside and outside
Women's History:
Obstetric History:
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.?
Yes
No
Please explain
Menstrual History:
Age at first period
Date of last menstrual period
MM slash DD slash YYYY
Length of cycle
Time between cycles
Cramping?
Yes
No
Pain?
Yes
No
Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)?
Yes
No
Please describe:
Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)?
Yes
No
Please describe:
Use of hormonal birth control:
Birth control pills
Patch
Nuva ring
Other
How long
Any problems with hormonal birth control?
Yes
No
Explain
Use of other contraception?
Yes
No
Condoms
Diaphragm
IUD
Are you in menopause?
Yes
No
Age at last period:
Was it surgical menopause?
Yes
No
Explain surgery:
Do you currently have symptomatic problems with menopause?
(Check all that apply)
Hot flashes
Mood swings
Concentration/memory problems Headaches
Vaginal dryness
Weight gain
Decreased libido
Loss of control of urine
Palpitations
Are you on hormone replacement therapy?
Yes
No
For how long and for what reason (hot flashes, osteoporosis prevention, etc.)?
Other Gynecological Symptoms:
(Check all that apply)
Endometriosis
Infertility
Fibrocystic breasts
Vaginal infection
Ovarian cysts
Pelvic inflammatory disease
Reproductive cancer
Sexually transmitted disease (describe)
Select All
Describe
Gynecological Screening/Procedures:
(If applicable, provide date)
Last Pap test:
Results:
Normal
Abnormal
Last mammogram:
Results:
Normal
Abnormal
Last bone density:
Results:
High
Low
Within Normal Range
Other tests/procedures (list type and dates)
Family History:
Write (Yes/No) for family members that have/had any of the following
Age (if still alive)
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Age at death (if deceased)
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Cancer
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Heart disease
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Hypertension
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Obesity
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Diabetes
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Stroke
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Autoimmune disease
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Arthritis
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Kidney disease
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Thyroid problems
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Seizures/epilepsy
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Psychiatric disorders
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Anxiety
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
Depression
Mother
Father
Brother(s)
Sister(s)
Child
Child
Child
Child
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Add
Remove
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
Yes
Past
GERD (reflux)
Yes
Past
Crohn's disease/ulcerative colitis
Yes
Past
Peptic ulcer disease
Yes
Past
Celiac disease
Yes
Past
Other:
Respiratory:
Bronchitis
Yes
Past
Asthma
Yes
Past
Emphysema
Yes
Past
Sinusitis
Yes
Past
Sleep apnea
Yes
Past
Other:
Urinary/Genital:
Kidney stones
Yes
Past
Gout
Yes
Past
Interstitial cystitis
Yes
Past
Frequent yeast infections
Yes
Past
Frequent urinary tract infections
Yes
Past
Sexual dysfunction
Yes
Past
Sexually transmitted diseases
Yes
Past
Other:
Endocrine/Metabolic:
Diabetes
Yes
Past
Hypothyroidism (low thyroid)
Yes
Past
Hyperthyroidism (overactive thyroid)
Yes
Past
Polycystic
Yes
Past
Ovarian
Yes
Past
Syndrome
Yes
Past
Infertility
Yes
Past
Metabolic syndrome/insulin resistance
Yes
Past
Eating disorder
Yes
Past
Hypoglycemia
Yes
Past
Other:
Musculoskeletal:
Fibromyalgia
Yes
Past
Osteoarthritis
Yes
Past
Chronic pain
Yes
Past
Other:
Skin:
Eczema
Yes
Past
Psoriasis
Yes
Past
Acne
Yes
Past
Skin cancer
Yes
Past
Other:
Cardiovascular:
Angina
Yes
Past
Heart attack
Yes
Past
Heart failure
Yes
Past
Hypertension (high blood pressure)
Yes
Past
Stroke
Yes
Past
High blood fats (cholesterol, triglycerides)
Yes
Past
Rheumatic fever
Yes
Past
Arrhythmia (irregular heart rate)
Yes
Past
Murmur
Yes
Past
Mitral valve prolapse
Yes
Past
Other:
Neurologic/Emotional:
Epilepsy/Seizures
Yes
Past
ADD/ADHD
Yes
Past
Headaches
Yes
Past
Migraines
Yes
Past
Depression
Yes
Past
Anxiety
Yes
Past
Autism
Yes
Past
Multiple sclerosis
Yes
Past
Parkinson's disease
Yes
Past
Dementia
Yes
Past
Other:
Cancer:
Lung
Yes
Past
Breast
Yes
Past
Colon
Yes
Past
Ovarian
Yes
Past
Skin
Yes
Past
Other:
Medical History (cont)
Diagnostic Studies
Date
Comments
Bone density
Date
Comments
CT scan
Date
Comments
Colonoscopy
Date
Comments
Cardiac stress test
Date
Comments
EKG
Date
Comments
MRI
Date
Comments
Upper endoscopy
Date
Comments
Upper GI series
Date
Comments
Chest
Date
Comments
X-ray
Date
Comments
Other
Date
Comments
Surgeries
Appendectomy
Date
Comments
Appendectomy
Date
Comments
Dental
Date
Comments
Gallbladder
Date
Comments
Hernia
Date
Comments
Hysterectomy
Date
Comments
Tonsillectomy
Date
Comments
Joint replacement
Date
Comments
Heart surgery
Date
Comments
Other:
Date
Comments
Other Information
List
Hospitalizations
Date
Reason
Add
Remove
Symptom Review
Please check
if these symptoms occur presently or have occurred in the last 6 months
General
Cold hands and feet
Mild
Moderate
Severe
Cold intolerance
Mild
Moderate
Severe
Daytime sleepiness
Mild
Moderate
Severe
Difficulty falling asleep
Mild
Moderate
Severe
Early waking
Mild
Moderate
Severe
Fatigue
Mild
Moderate
Severe
Fever
Mild
Moderate
Severe
Flushing
Mild
Moderate
Severe
Heat intolerance
Mild
Moderate
Severe
Night waking
Mild
Moderate
Severe
Nightmares
Mild
Moderate
Severe
Can't remember dreams
Mild
Moderate
Severe
Low body temperature
Mild
Moderate
Severe
Head, Eyes, and Ears
Conjunctivitis
Mild
Moderate
Severe
Distorted sense of smell
Mild
Moderate
Severe
Distorted taste
Mild
Moderate
Severe
Ear fullness
Mild
Moderate
Severe
Ear ringing/buzzing
Mild
Moderate
Severe
Eye crusting
Mild
Moderate
Severe
Eye pain
Mild
Moderate
Severe
Eyelid margin redness
Mild
Moderate
Severe
Headache
Mild
Moderate
Severe
Hearing loss
Mild
Moderate
Severe
Hearing problems
Mild
Moderate
Severe
Migraine
Mild
Moderate
Severe
Sensitivity to loud noises
Mild
Moderate
Severe
Vision problems
Mild
Moderate
Severe
Musculoskeletal
Back muscle spasm
Mild
Moderate
Severe
Calf cramps
Mild
Moderate
Severe
Chest tightness
Mild
Moderate
Severe
Foot cramps
Mild
Moderate
Severe
Joint deformity
Mild
Moderate
Severe
Joint pain
Mild
Moderate
Severe
Joint redness
Mild
Moderate
Severe
Joint stiffness
Mild
Moderate
Severe
Muscle pain
Mild
Moderate
Severe
Muscle stiffness
Mild
Moderate
Severe
Muscle spasms
Mild
Moderate
Severe
Muscle twitches:
Mild
Moderate
Severe
Around eyes
Mild
Moderate
Severe
Arms or legs
Mild
Moderate
Severe
Muscle weakness
Mild
Moderate
Severe
Musculoskeletal (cont.)
Neck muscle spasm
Mild
Moderate
Severe
Tendonitis
Mild
Moderate
Severe
Tension headache
Mild
Moderate
Severe
TMJ problems
Mild
Moderate
Severe
Mood/Nerves
Agoraphobia
Mild
Moderate
Severe
Anxiety
Mild
Moderate
Severe
Auditory hallucinations
Mild
Moderate
Severe
Blackouts
Mild
Moderate
Severe
Depression
Mild
Moderate
Severe
Depression
Mild
Moderate
Severe
Difficulty:
Concentrating
Mild
Moderate
Severe
With balance
Mild
Moderate
Severe
With thinking
Mild
Moderate
Severe
With judgment
Mild
Moderate
Severe
With speech
Mild
Moderate
Severe
With memory
Mild
Moderate
Severe
Dizziness (spinning)
Mild
Moderate
Severe
Fainting
Mild
Moderate
Severe
Fearfulness
Mild
Moderate
Severe
Irritability
Mild
Moderate
Severe
Light-headedness
Mild
Moderate
Severe
Numbness
Mild
Moderate
Severe
Other phobias
Mild
Moderate
Severe
Panic attacks
Mild
Moderate
Severe
Paranoia
Mild
Moderate
Severe
Suicidal thoughts
Mild
Moderate
Severe
Seizures
Mild
Moderate
Severe
Tingling
Mild
Moderate
Severe
Tremor/trembling
Mild
Moderate
Severe
Visual hallucinations
Mild
Moderate
Severe
Symptom Review (cont.)
Please check if these symptoms occur presently or have occurred in the last 6 months
Urinary:
Bed wetting
Mild
Moderate
Severe
Hesitancy
Mild
Moderate
Severe
Infection
Mild
Moderate
Severe
Kidney disease
Mild
Moderate
Severe
Kidney stone
Mild
Moderate
Severe
Leaking/incontinence
Mild
Moderate
Severe
Pain/burning
Mild
Moderate
Severe
Urgency
Mild
Moderate
Severe
Digestion:
Anal spasms
Mild
Moderate
Severe
Bad teeth
Mild
Moderate
Severe
Bleeding gums
Mild
Moderate
Severe
Bloating of:
Mild
Moderate
Severe
Lower abdomen
Mild
Moderate
Severe
Whole abdomen
Mild
Moderate
Severe
Bloating after meals
Mild
Moderate
Severe
Blood in stools
Mild
Moderate
Severe
Burping
Mild
Moderate
Severe
Canker sores
Mild
Moderate
Severe
Cold sores
Mild
Moderate
Severe
Constipation
Mild
Moderate
Severe
Cracking at corner of lips
Mild
Moderate
Severe
Dentures w/poor chewing
Mild
Moderate
Severe
Diarrhea
Mild
Moderate
Severe
Difficulty swallowing
Mild
Moderate
Severe
Dry mouth
Mild
Moderate
Severe
Farting
Mild
Moderate
Severe
Fissures
Mild
Moderate
Severe
Foods "repeat" (reflux)
Mild
Moderate
Severe
Heartburn
Mild
Moderate
Severe
Hemorrhoids Intolerance to:
Mild
Moderate
Severe
Lactose
Mild
Moderate
Severe
All dairy products
Mild
Moderate
Severe
Gluten (wheat)
Mild
Moderate
Severe
Corn
Mild
Moderate
Severe
Eggs
Mild
Moderate
Severe
Fatty foods
Mild
Moderate
Severe
Yeast
Mild
Moderate
Severe
Liver disease/jaundice (yellow eyes or skin)
Mild
Moderate
Severe
Lower abdominal pain
Mild
Moderate
Severe
Mucus in stools
Mild
Moderate
Severe
Digestion (cont.):
Nausea
Mild
Moderate
Severe
Bulimia
Mild
Moderate
Severe
Periodontal disease
Mild
Moderate
Severe
Sore tongue
Mild
Moderate
Severe
Strong stool odor
Mild
Moderate
Severe
Undigested food in stools
Mild
Moderate
Severe
Upper abdominal pain
Mild
Moderate
Severe
Vomiting
Mild
Moderate
Severe
Eating:
Binge eating
Mild
Moderate
Severe
Can't gain weight
Mild
Moderate
Severe
Can't lose weight
Mild
Moderate
Severe
Carbohydrate craving
Mild
Moderate
Severe
Carbohydrate intolerance
Mild
Moderate
Severe
Poor appetite
Mild
Moderate
Severe
Salt cravings
Mild
Moderate
Severe
Frequent dieting
Mild
Moderate
Severe
Sweet cravings
Mild
Moderate
Severe
Caffeine dependency
Mild
Moderate
Severe
Breathing:
Bad breath
Mild
Moderate
Severe
Bad odor in nose
Mild
Moderate
Severe
Cough - dry
Mild
Moderate
Severe
Cough - productive
Mild
Moderate
Severe
Hayfever:
Mild
Moderate
Severe
Spring Summer
Mild
Moderate
Severe
Fall
Mild
Moderate
Severe
Change of season
Mild
Moderate
Severe
Hoarseness
Mild
Moderate
Severe
Nasal stuffiness
Mild
Moderate
Severe
Nose bleeds
Mild
Moderate
Severe
Post nasal drip
Mild
Moderate
Severe
Sinus fullness
Mild
Moderate
Severe
Sinus infection
Mild
Moderate
Severe
Snoring
Mild
Moderate
Severe
Sore throat
Mild
Moderate
Severe
Wheezing
Mild
Moderate
Severe
Winter stuffiness
Mild
Moderate
Severe
Symptom Review (cont.)
Please check if these symptoms occur presently or have occurred in the last 6 months
Nails:
Bitten
Mild
Moderate
Severe
Brittle
Mild
Moderate
Severe
Curve up
Mild
Moderate
Severe
Frayed
Mild
Moderate
Severe
Fungus - fingers
Mild
Moderate
Severe
Fungus - toes
Mild
Moderate
Severe
Pitting
Mild
Moderate
Severe
Ragged cuticles
Mild
Moderate
Severe
Ridges
Mild
Moderate
Severe
Soft
Mild
Moderate
Severe
Thickening of: Finger nails
Mild
Moderate
Severe
Thickening of: Toenails
Mild
Moderate
Severe
White spots/lines
Mild
Moderate
Severe
Lymph Nodes:
Enlarged/neck
Mild
Moderate
Severe
Tender/neck
Mild
Moderate
Severe
Enlarged/neck
Mild
Moderate
Severe
Other enlarged/tender
Mild
Moderate
Severe
lymph nodes
Mild
Moderate
Severe
Skin, Dryness of:
Eyes
Mild
Moderate
Severe
Feet: Any cracking?
Mild
Moderate
Severe
Feet: Any peeling?
Mild
Moderate
Severe
Hair: And unmanageable?
Mild
Moderate
Severe
Hands: Any cracking?
Mild
Moderate
Severe
Hands: Any peeling?
Mild
Moderate
Severe
Mouth/throat
Mild
Moderate
Severe
Scalp: Any dandruff?
Mild
Moderate
Severe
Skin in general
Mild
Moderate
Severe
Skin Problems (cont.):
Ears get red
Mild
Moderate
Severe
Easy bruising
Mild
Moderate
Severe
Eczema
Mild
Moderate
Severe
Herpes genital
Mild
Moderate
Severe
Hives
Mild
Moderate
Severe
Jock itch
Mild
Moderate
Severe
Lackluster skin
Mild
Moderate
Severe
Moles w color/size change
Mild
Moderate
Severe
Oily skin
Mild
Moderate
Severe
Pale skin
Mild
Moderate
Severe
Patchy dullness
Mild
Moderate
Severe
Psoriasis
Mild
Moderate
Severe
Rash
Mild
Moderate
Severe
Red face
Mild
Moderate
Severe
Sensitive to bites
Mild
Moderate
Severe
Sensitive to poison ivy/oak
Mild
Moderate
Severe
Shingles
Mild
Moderate
Severe
Skin cancer
Mild
Moderate
Severe
Skin darkening
Mild
Moderate
Severe
Strong body odor
Mild
Moderate
Severe
Thick calluses
Mild
Moderate
Severe
Vitiligo
Mild
Moderate
Severe
Itching Skin:
Anus
Mild
Moderate
Severe
Arms
Mild
Moderate
Severe
Ear canals
Mild
Moderate
Severe
Eyes
Mild
Moderate
Severe
Feet
Mild
Moderate
Severe
Hands
Mild
Moderate
Severe
Legs
Mild
Moderate
Severe
Nipples
Mild
Moderate
Severe
Nose
Mild
Moderate
Severe
Genitals
Mild
Moderate
Severe
Roof of mouth
Mild
Moderate
Severe
Scalp
Mild
Moderate
Severe
Skin in general
Mild
Moderate
Severe
Throat
Mild
Moderate
Severe
Symptom Review (cont.)
Please check if these symptoms occur presently or have occurred in the last 6 months
Female Reproductive:
Breast cysts
Mild
Moderate
Severe
Breast lumps
Mild
Moderate
Severe
Breast tenderness
Mild
Moderate
Severe
Ovarian cyst
Mild
Moderate
Severe
Poor libido (sex drive)
Mild
Moderate
Severe
Endometriosis
Mild
Moderate
Severe
Fibroids
Mild
Moderate
Severe
Infertility
Mild
Moderate
Severe
Vaginal discharge
Mild
Moderate
Severe
Vaginal odor
Mild
Moderate
Severe
Vaginal itch
Mild
Moderate
Severe
Vaginal pain
Mild
Moderate
Severe
Premenstrual:
Mild
Moderate
Severe
Bloating
Mild
Moderate
Severe
Breast tenderness
Mild
Moderate
Severe
Carbohydrate craving
Mild
Moderate
Severe
Chocolate craving
Mild
Moderate
Severe
Constipation
Mild
Moderate
Severe
Decreased sleep
Mild
Moderate
Severe
Fatigue
Mild
Moderate
Severe
Diarrhea
Mild
Moderate
Severe
Increased sleep
Mild
Moderate
Severe
Irritability
Mild
Moderate
Severe
Menstrual:
Mild
Moderate
Severe
Cramps
Mild
Moderate
Severe
Irregular periods
Mild
Moderate
Severe
Heavy periods
Mild
Moderate
Severe
No periods
Mild
Moderate
Severe
Scanty periods
Mild
Moderate
Severe
Spotting between
Mild
Moderate
Severe
Current Medications
Current medications (include prescription and over-the-counter)
Current Medications
Medication
Dosage
Start Date
Reason for Use
Add
Remove
Current Supplements
Current Supplements
Supplements
Dosage
Start Date
Reason for Use
Add
Remove
Have medications or supplements ever caused unusual side effects or problems?
Yes
No
Describe:
Have you used any of these regularly or for a long time:
NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin?
Yes
No
Tylenol (acetaminophen)?
Yes
No
Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?
Yes
No
How many times have you taken antibiotics?
Infancy/Childhood
>5
<5
Reson for Use
Add
Remove
Teen
>5
<5
Reson for Use
Add
Remove
Adulthood
>5
<5
Reson for Use
Add
Remove
Have you ever taken long-term antibiotics?
Yes
No
Describe:
How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)
Infancy/Childhood
>5
<5
Reson for Use
Add
Remove
Teen
>5
<5
Reson for Use
Add
Remove
Adulthood
>5
<5
Reson for Use
Add
Remove
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
5
4
3
2
1
Take several nutritional supplements each day
5
4
3
2
1
Keep a record of everything you eat each day
5
4
3
2
1
Modify your lifestyle (e.g., work demands, sleep habits)
5
4
3
2
1
Practice a relaxation technique
5
4
3
2
1
Engage in regular exercise
5
4
3
2
1
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?
5
4
3
2
1
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?
5
4
3
2
1
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?
5
4
3
2
1
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?
