Date of last physical

Practitioner Name

Practitioner Phone Number

Laboratory procedures performed (e.g stool analysis, blood and urine chemistries, hair analysis)

What was the outcome of these procedures:

What types of therapy have you tried for this problem(s):

Diet ModificationFastingVitamins/MineralsHerbsHomeopathyChiropracticAcupunctureConventional drugsOther

List current health problems for which you are beong treated:

Current Medications (prescription or over-the-counter):

Please list all procedures, complications(if any) and dates:

Select the level of stress you are experiencing:

1 - Not Stressed at all2345 - somewhat stressed678910 - Extreme stress

Identify the major causes of your stress (e.g.: Changes in Job, Work, Residence or Finances, Legal Problems):

Regarding your weight, do you consider yourself:

—Please choose an option—UnderweightOverweightJust Right

What is your weight today:

lbs

Have you had an unintentional weight loss or gain of 10 lbs or more in the last three months?

YesNo

Is your job associated With potentially harmful chemicals (e.g .. pesticides, radioactivity, solvents) or health and/or life-threatening activities (e.g.: Fireman, Farmer, Miner)?

Do you use any of the following? (select all that apply):

Corrective lensesDenturesHearing aid

Medical Devices/Prosthetics/Implants (describe):

Have there been any recent changes in your ability to (select all that apply):

SeeHearTasteSmellFeel Hot/Cold SensationsMove around (sit upright, Stand, Walk, Run, Pick up things, Swing your arms freely, Turn your head, Wiggle fingers)

Do you have a strong like for any of the following flavors (select all that apply):
SourBitterSweetRich/FattySpicy/PungentSalty

Do you have a strong dislike for any one of the following flavors (select all that apply):
SourBitterSweetRich/FattySpicy/PungentSalty

Do you prefer warmth or cold?
—Please choose an option—Warmth (i.e.: food, drinks, weather, etc.)Cold (i.e.: food, drinks, weather, etc.)No preference

Is your sleep disturbed at the same time each night?

YesNo

If yes, what time?

[time sleeptime class:short time-format:hh:mm tt placeholder "12:00 AM"]

Time of day you feel the most energy or the least symptoms:

—Please choose an option—7am to 9am9am to 11am11am to 1pm1pm to 3pm3pm to 5pm5pm to 7pm7pm to 9pm9pm to 11pm11pm to 1am1am to 3am3am to 5am5am to 7am

Time of day you feel the worst or your symptoms are aggravated:

—Please choose an option—7am to 9am9am to 11am11am to 1pm1pm to 3pm3pm to 5pm5pm to 7pm7pm to 9pm9pm to 11pm11pm to 1am1am to 3am3am to 5am5am to 7am

Do you experience any of these general symptoms every day (select all that apply)?

Debilitating fatigueDepressionDisinterest in sexDisinterest in eatingShortness of breathPanic attacksHeadachesDizzinessInsomnia

NauseaVomitingDiarrheaConstipationFecal incontinenceUrinary incontinenceLow grade feverChronic pain/inflammationBleeding DischargeItching/rash

Select All that apply

ArthritisAllergies/Hay feverAsthmaAlcoholismAlzheimer's diseaseAutoimmune diseaseBlood pressure problemsBronchitisCancerChronic fatigue syndromeCarpal tunnel syndromeCholesterol, elevatedCirculatory problemsColitisDental problemsDepressionDiabetesDiverticular diseaseDrug addictionEating disorderEpilepsyEmphysemaEyes, ears, nose, throat problemsEnvironmental sensitivitiesFibromyalgiaFood IntoleranceGastroesophageal reflux diseaseGenetic disorderGlaucoma

GoutHeart diseaseInfection, chronicInflammatory bowel diseaseIrritable bowel syndromeKidney or bladder diseaseLearning disabilitiesLiver or gallbladder disease (stones)Mental illnessMental retardationMigraineheadachesNeurological problems (Parkinson's, paralysis)Sinus problemsStrokeThyroid troubleObesityOsteoporosisPneumoniaSexually transmitted diseaseSeasonal affective disorderSkin problemsTuberculosisUlcerUrinary tract infectionVaricose veinsOther

Select All that apply

Benign prosatic hypertasia (BPH)Prostate cancerDecreased sex driveInfertilitySexually transmitted diseaseOther

Select All that apply

Menstrual irregularitiesEndometriosisInfertilityFibrocystic BreastsFibroids/Ovarian CystsPremenstrual syndrome (PMS)

Breast cancerPelvic inflammatory diseaseVaginal InfectionsDecreased sex driveSexually trammitted disease
Other

Age of first period:

Date of last gynecological exam:

Mammogram

—Please choose an option—Positive (+)Negative (-)

FAP

—Please choose an option—Positive (+)Negative (-)

What form of birth control do you use?:

No. of pregnancies

Have you ever had (select all that apply)

C-SectionSurgical menopauseMenopause

Date of last menstrual cycle:

Length of cycle (days):

Time between cycles (days)

Any recent changes in normal menstrual flow? (e.g.: heavier, large clots, scanty):

Select all that apply

ArthritisAsthmaAlcoholismAlzheimer's diseaseCancerDepressionDiabetesDrug addictionEating DisorderGenetic disorderGlaucomaHeart diseaseInfertility

Learning disabilitiesMental illnessMental retardationMigraine headachesNeurological disorders (Parkinson's, paralysis)ObesityOsteoporosisStrokeSuicideOther

Tobacco

• Cigarettes (Number per day):

• Cigars (Number per day):

Alcohol

Wine

• Day (Number of glasses):

• Week (Number of glasses):

Liquor

• Day (Number of Ounces):

• Week (Number of Ounces):

Beer

• Day (Number of glasses):

• Week (Number of glasses):

Caffeine

• Coffee: Number of 6oz Cups per day:

• Tea: Number of 6oz Cups per day:

• Soda (caffeinated): Number of 6oz Cups per day:

Water

• Number of glasses per day:

Exercise

Amount:
5-7 days per week3-4 days per week1-2 days per week

Duration
45 minutes or more 45 minutes or more duration per workout30 to 45 minutes per workoutLess than 30 minutes

Exercises (select all that apply):
WalkRun, Jog, Jump ropeWeight liftingSwimBoxYoga

Select all that apply

Mixed food diet (animal and vegetable sources)VegetarianVeganSalt restrictionFat restrictionStarch/carbohydrate restrictionThe Zone DietTotal calorie restriction

Specific food restrictions (select all that apply)

DairyWheatEggsSoyCornAll gluten

Other

Food Frequency

Servings per day:

• Fruits (citrus, melons, etc.):

• Dark green or deep yellow/ orange vegetables:

• Grains (unprocessed):

• Beans, Pasta, Legumes:

• Dairy, eggs:

• Meat, Poultry, Fish:

Do you regularly:

Skip breakfastTwo Meals/dayOne Meal/dayGraze (small frequent meals)

Food rotationEat constantly whether hungry or notGenerally eat on the runAdd salt to food

Current Supplements

Multivitamin/mineralVitamin CVitamin EEPA/DHAEvening Primrose/GIA
Calcium

MagnesiumZinc
minerals

Friendly flora (acidophilus)Digesive enzymesAmino acids

CoQ10Antioxidants (e.g.: Lutein, resvertrol etc.)Herbs (teas)Herbs (extracts)Chinese herbsAyurvedic herbsHomeopathyBach flowersProtein shakesSuperfoods (e.g.: Bee pollen, phytonutrient blends)Liquid meals
Other: