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Patient Intake Form
New Patient Intake Form
Multi-page intake form on Wellness Evolutions, plus the detox form and all other forms on my website.
Step
1
of
22
4%
Name
*
First
Last
Preferred Name
*
Height
*
Weight
*
Age
*
Date of Birth
*
MM slash DD slash YYYY
Place of Birth
*
Gender
*
Male
Female
Marital Status
*
Single
Partnered
Married
Separated
Divorced
Widowed
Occupation
*
Hours Per Week
*
Date of last physical exam.
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
*
Work Phone
Cell Phone
Email
*
How did you hear about my services?
Next of kin or other to reach in an emergency:
*
First
Last
Relationship
*
Phone
*
In case of emergency contact:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
GENETIC BACKGROUND: Please check appropiated box(es):
*
African American
Native American
Hispanic
Caucasian
Mediterranean
Northern European
Asian
Other
Who is your primary medical physician?
*
Primary medical physician address & office phone #
*
How did you hear about my practice?
*
Book
Website
Friend/Family member
Other Hospitalizations
*
Yes
No
Have you ever had a blood transfusion?
*
Yes
No
Personal Health History
Childhood Illness:
Measles
Mumps
Rubella
Chicken Pox
Rheumatic Fever
Polio
Immunization and dates:
Tetanus
Pneumonia
Hepatitis
Shingles
Chicken Pox
Chicken Pox
MMR Measles Mumps Rubella
List any medical problems that other doctors have diagnosed
*
SURGERIES
*
Please list Year, Reason, Hospital
OTHER HOSPITALIZATIONS
*
Please list Year, Reason, Hospital
FUNCTIONAL DIAGNOSTIC MEDICINE QUESTIONAIRE
Please indicate the type of medications you are taking now (prescription and non-prescription drugs)
*
Please list Medication Name, Dose, Frequency, Date Started, Reason for Use
Supplements: List all vitamins, minerals and other nutritional supplements
*
Please list Supplement Brand/Name, Dose, Frequency, Date Started, Reason for use
Have medications or supplements ever caused you unusual side effects or problems?
*
Yes or No. If yes, please describe.
Allergies
*
Please list your allergies. Include Medication/Supplement/Food and the Reaction.
FUNCTIONAL DIAGNOSTIC MEDICINE QUESTIONNAIRE
Please complete the following functional medicine questionnaire to the best of your ability. You may need family members to help supply information. Your thoroughness and accuracy in answering all appropriate questions will help me evaluate the root cause of your health concerns and determine an effective treatment program.
COMPLAINTS / CONCERNS
*
Please list your chief symptoms in order of decreasing severity, starting with the worst one (Problem, On set, Frequency, Severity)
What diagnosis or explanation was given to you?
*
When was the last time that you felt well?
*
Did something trigger your change in health?
*
What makes you feel worse?
*
What makes you feel better?
*
Please list all physicians you have seen for the above health conditions:
*
Please check all the Alternative Treatments you have tried for your condition (s):
*
None
Massage
Yoga
Environmental Medicine
Chiropractic
Rolfing
Hypnosis
Nutritional Therapy
Acupuncture
Reiki
Ayurveda
Biological Dentistry
Iridology
Homeopathy
Light Therapy
IV (Chelation) Therapy
Colonics
Biofeedback/Neurofeedback
Meditation
Naturopathic Medicine
Osteopathic Manipulation
Physical Therapy
Energy Practices/Metaphysics
Psychotherapy
IV Therapy
Detoxification
Psychedelic Therapy
FEMALE MEDICAL HISTORY (FOR WOMEN ONLY)
OBSTETRICAL HISTORY
Pregnancies
Caesarean Births
Vaginal Deliveries
Miscarriages
Abortions
Living Children
Post-partum Depression
Toxemia
Gestational Diabetes
Baby Over 8 pounds
Breast feeding?
GYNECOLOGYCAL HISTORY
Age at first period:
Please enter a number from
0
to
99
.
Menses Frequency:
Length
Pain
Yes
No
Clotting
Yes
No
Has your period skipped?
Yes
No
If yes, for how long?
Last Menstrual Period:
Do you currently use contraception:
Yes
No
If yes, what type do you use?
Condom
Diaphragm
IUD
Partner Vasectomy
Have you ever used hormonal contraception?
Yes
No
If yes, when?
Use of hormonal contraception:
Birth Control Pills
Patch
NuvaRing How long?
Are you using the pill now?
Yes
No
Did/does taking the pill agree with you?
Yes
No
In the 2nd half of your cycle, do you have symptoms of breast tenderness, water retention, food cravings, or irritability (PMS)?
Yes
No
Last Mammogram
Breast Biopsy/Date?
Last PAP Test:
Normal
Abnormal
Date Of Last Bone Density Test/DEXA Scan
Results:
High
Low
Within normal range
Are you in Menopause?
Yes
No
Age at Menopause:
Please enter a number from
0
to
99
.
Do you Take:
Estrogen
Ogen
Estrace
Premarin
Progesterone
Provera
If yes, then for how long and what kind?
MALE MEDICAL HISTORY (FOR MEN ONLY)
Do you usually get up to urinate during the night?
Yes
No
If yes, number of times:
Do you feel pain or burning during the urination?
Yes
No
Any blood in your urine?
Yes
No
Do you feel burning discharge from penis?
Yes
No
Has the force of your urination decreased?
Yes
No
Have you had any kidney, bladder or prostate infections within the last 12 months?
Yes
No
Do you have any problems emptying your bladder completely?
Yes
No
Any difficulty with erection or ejaculation?
Yes
No
Any testicle pain or swelling?
Yes
No
Date of last or prostate exam:
MM slash DD slash YYYY
PAST MEDICAL AND FAMILY HISTORY
Please state any health problem (s) you or your family has suffered with, either now or in the past
*
Any other family we should know about?
*
If Yes, please comment
What is the attitude of those close to you, about your illness?
*
Supportive
Non-supportive
SOCIAL HISTORY
PSYCHOSOCIAL
Do you feel significantly less vital than you did a year ago?
*
Yes
No
Are you happy?
*
Yes
No
Do you feel your life has meaning and purpose?
*
Yes
No
Do you believe stress is presently reducing the quality of your life?
*
Yes
No
Do you like the work you do?
*
Yes
No
Have you experienced major loses in your life?
*
Yes
No
Do you spend the majority of your time and money to fulfill responsibilities and obligations?
*
Yes
No
Mental Health
Is stress a major problem for you?
*
Yes
No
Do you feel depressed?
*
Yes
No
Do you panic when stressed?
*
Yes
No
Do you have problems with eating or your appetite?
*
Yes
No
Do you cry frequently?
*
Yes
No
Have you ever seriously thought about hurting yourself?
*
Yes
No
Do you have trouble sleeping?
*
Yes
No
Do you frequently experience anxiety?
*
Yes
No
Do you suffer from mood swings?
*
Yes
No
Do you have difficulty getting motivated?
*
Yes
No
Do you frequently experience feelings of agitation, anger, fear, or worry?
*
Yes
No
Do you have a childhood history or any history of trauma in your past (such as rape, violence, natural disaster, bullying)?
*
Yes
No
If yes, describe
Were there any substance abuse problems in your family as you grew up?
*
Yes
No
If yes, describe
When you were growing up, did anyone in the family, including a parent, suffer from a chronic disease, or a mental disease?
*
Yes
No
If yes, describe
Overall, did you feel safe as a child and securely bonded to your parents? Did you feel you could completely trust your parents/parent to take care of you?
*
Yes
No
Do you feel less able to handle stress or experience more stress now than in the past?
*
Yes
No
Check off from this list the things you do to handle daily stress:
*
Excercise
Regular Vacations
Play with pets
Baths/Jacuzzi/Saunas
Comfort Eat / Cook
Get body work (massages, facials, etc)
Long walks / Hikes / Nature
Talk with family / Friends
Read
Watch tv / Movies
Meditate / Yoga / Taiichi
Sleep
Hobbies
Alcohol
Other
Are you having any sexual problems?
*
Yes
No
DIET AND GASTROINTESTINAL HEALTH
Do you consume at least five servings of fruits and vegetables per day?
*
Yes
No
Are you on any structured diet at this time?
*
Yes
No
Have you dieted many times in the past?
*
Yes
No
If yes, what diets were you on?
Are you dieting now?
*
Yes
No
If yes, what is it?
# of meals you eat in an average day
*
Do you drink at least 4-6 glasses of water or equivalent beverages per day?
*
Yes
No
Have you ever been diagnosed with a chronic GI condition?
*
Yes
No
Do you typically snack on chips, cookies, crackers or granola bars?
*
Yes
No
Do you regularly consume soft drinks or fruit juices?
*
Yes
No
How many regular sodas do you consume per day?
*
Please enter a number from
0
to
99
.
Do you have frequent sugar cravings?
*
Yes
No
Do you eat within three hours of bedtime?
*
Yes
No
Do you regularly eat at restaurants or consume processed foods from the grocery store?
*
Yes
No
Do you experience frequent heartburn, burping, gas, pain, constipation/diarrhea, or bloating?
*
Yes
No
Do you regularly have less than one or more than three bowel movements per day?
*
Yes
No
Do you take a laxative more than twice a month?
*
Yes
No
Have you used antibiotic medications within the last two years?
*
Yes
No
Do you consume alcohol, antacids or anti-inflammatory/pain killer drugs regularly?
*
Yes
No
Has there been a period when you consumed more alcohol that you presently do?
*
Yes
No
Have you ever been diagnosed with anemia or any other nutrient deficiency?
*
Yes
No
Have you ever been placed on a heartburn medication/acid blocker (proton pump inhibitor (PPI) or H2 blocker)?
*
Yes
No
Do you frequently experience indigestion?
*
Yes
No
Do you experience poor memory, difficulty concentrating or brain fog?
*
Yes
No
Have you ever been diagnosed with depression, anxiety, ADD or ADHD?
*
Yes
No
Do you suffer from multiple food sensitivities?
*
Yes
No
OVERALL IMMUNE AND INFLAMMATORY BALANCE
Do you tend to catch colds and respiratory diseases easily or recover slowly from illness?
*
Yes
No
Have you been diagnosed with a recent or chronic infection (such as Lyme disease, Epstein-Barr, Candidiasis, and Herpes Simplex)?
*
Yes
No
Do you have unexplained rashes, redness or itching?
*
Yes
No
Do you suffer now or have in the past from chronic fatigue, chronic pain, fibromyalgia or migraine headaches?
*
Yes
No
Do you suffer from any auto-immune condition such as MS, lupus, or rheumatoid arthritis?
*
Yes
No
Do you suffer from food allergies and seasonal allergies?
*
Yes
No
Do you suffer from hives, eczema, rosacea, or psoriasis?
*
Yes
No
Do you tend to put people and family and situations first and your needs and goals second?
*
Yes
No
ENVIRONMENTAL FACTORS IN HEALTH
Do you use sleeping aids?
*
Yes
No
If yes, explain:
Do you feel rested upon awakening most mornings?
*
Yes
No
Are there any physical or mental abuses issues in your life that you would like to discuss?
*
Yes
No
Are you sensitive to smells and fragrances?
*
Yes
No
Most nights, how many times do you awake?
*
Do you have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, paint, cleaning chemicals, or volatile fumes?
*
Yes
No
How many hours of sleep do you get most nights?
*
Most nights are you able to fall asleep within 15 minutes?
*
Yes
No
Do you suffer from light cycle disruption or shift work issues?
*
Yes
No
Do you frequently feel drowsy throughout the day?
*
Yes
No
How many root canals do you currently have in your mouth:
*
How many silver fillings do you currently have in your mouth:
*
Have you been told by your dentist that you have gum disease?
*
Yes
No
What kind of water do you drink on a regular basis?
*
Plastic Bottled
Tap water
Well water
Purified water system in the home
Filtered water from refrigerator or small counter filter
Do you use weed killers, pesticides, commercial cleaners in and around the home?
*
Yes
No
How long is your commute time to work (if applicable)?
Has anyone told you that you snore loudly?
*
Yes
No
Do you sleep in a totally dark bedroom?
*
Yes
No
Do you smoke now?
*
Yes
No
If yes, what kind of smoking and how much?
Did you ever smoke in the past?
*
Yes
No
If yes, how much and for how long?
Do you use commercial personal care products? (lotion, shampoo, cosmetics, etc.)
*
Yes
No
Women: Do you have breast implants?
*
Yes
No
If yes, what kind?
Do you have any metal devices implanted in your body?
*
Yes
No
If so, describe:
Do you use artificial sweeteners?
*
Yes
No
If yes, what kind?
How often do you barbeque meat on a grill?
*
Have you ever had a venereal disease?
*
Yes
No
If yes, what?
Do you have any history of recreational or street drugs and/or drug addiction?
*
Yes
No
If yes, explain
Have you ever given yourself street drugs with a needle?
*
Yes
No
Do you always wear a seatbelt when driving and as a passenger?
*
Yes
No
Is any litigation pending regarding a medical condition?
*
Yes
No
How many cat scans have you had in your life:
*
What part of the body were they done on?
*
HEALTH HABITS AND PERSONAL SAFETY
All questions contained in this questionnaire are required and will be kept strictly confidential.
Exercise
*
Sedentary (no exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet
Are you dieting?
*
Yes
No
If yes, are you on a physician prescribed medical diet?
*
Yes
No
Number of meals you eat on an average day?
*
Please enter a number from
0
to
10
.
Rank salt intake
*
Hi
Medium
Low
Rank fat intake
*
Hi
Medium
Low
Caffeine
Caffeine
*
None
Coffee
Tea
Cola or other caffeinated beverage
Number of cups/cans per day
Alcohol
Do you drink alcohol?
*
yes
no
If yes, what kind?
How many drinks per week?
Are you concerned about the amount you drink?
*
Yes
No
Have you considered stopping?
*
Yes
No
Have you ever experienced blackouts?
*
Yes
No
Are you prone to “binge” drinking?
*
Yes
No
Do you drive after drinking?
*
Yes
No
Tobacco
Do you use tobacco?
*
Yes
No
What kind of tobacco do you use?
Cigarettes
Chew
Pipe
Cigars
For how many years?
If you quit, what year?
Sex
Are you sexually active?
*
Yes
No
If yes, are you trying for pregnancy?
Yes
No
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort with intercourse?
*
Yes
No
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
*
Yes
No
Do you live alone?
*
Yes
No
Do you have frequent falls?
*
Yes
No
Do you have vision or hearing loss?
*
Yes
No
Do you have an Advanced Directive or Living Will?
*
Yes
No
Would you like information on the preparation of these?
*
Yes
No
Physical and/or mental abuse has also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss the issue with your provider?
*
Yes
No
Stress / Coping
Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immune system dysfunction. Witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.
Have you ever been involved in an abusive relationship in your life?
*
Yes
No
Is alcoholism or substance abuse present in your relationships now?
*
Yes
No
Have you ever sought counseling?
*
Yes
No
Currently going to counseling?
*
Yes
No
Previously going to counseling?
*
Yes
No
If previously, for how long and when?
If previously, what kind of counseling?
Comments
Do you feel you have any excessive amount of stress in your life?
*
Yes
No
Daily stressors: Rate in a scale from 1 - 10 (1 not stressful – 10 very stressful)
Work
Family
Social
Finances
Health
Other
Do you practice meditation or relaxation techniques?
Yes
No
How often do you meditate?
What ways so you reduce stress? Check all that apply.
Yoga
Meditation
Imagery
Breathing
Tai Chi
Prayer
Massage
Miinfulness Practice
Pets
Gardening
Hobbies
Other
Hobbies and leisure activities
How important is your religion (or spirituality) for you and your family life?
Not at all important
Somewhat important
Extremely important
How well have things been going for you?
At school, in your job, social life, close friends, sex, attitude, boyfriend/girlfriend, children, parents, and with your spouse?
Do you experience mental fogginess or have trouble concentrating?
Yes
No
In the last 6 months, have you unintentionally lost or gained 10 or more pounds?
Yes
No
Do you wake up feeling unrested or depend on caffeine to keep you going throughout the day?
Yes
No
Do you feel overly stressed most days?
Yes
No
Generally speaking, do you enjoy exercising?
Yes
No
In the last month, how many exercise sessions did you complete?
What is the average length of time of your exercise sessions?
Is your job:
Active
Sedentary?
How many hours a day are you sitting down (include travel time)?
What kind of exercise and activity do you mostly do? Include gardening, housework, yard work, recreational activities, etc?
Which of the following provide you emotional support? Check all that apply
Spouse
Family
Friends
Religious/Spiritual
Pets
Hobbies
Group Memberships
Other
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
*
5
4
3
2
1
Practice relaxation techniques
*
5
4
3
2
1
Engage in regular exercises
*
5
4
3
2
1
Have periodic lab tests to assess progress
*
5
4
3
2
1
Comments:
Rate on a scale of: 5 (very confident) to 1 (not confident)
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 not are confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in the above activities?:
*
Rate on a scale of: 5 (very supportive) to 1 (not supportive at all)
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
Comments:
Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact)
How much ongoing support and contact (e.g. telephone consults, e-mail correspondence) from me would be helpful for you as you implement your personal health program?
*
5
4
3
2
1
Comments:
Health And Wellness
STEP ONE What Is Your Current “Health Blueprint”?
On a scale of 0-10, (0 = ‘I’m a train wreck’); (10 = ‘I feel so good I can’t stand it’) how would you rate your health now?
*
Using the same scale of 0-10, listed above, how would you rate your life now?
*
What is your #1 health complaint?
*
How long have you had this issue?
*
What were your results?
*
What has someone suggested you do for this condition that you have resisted doing or procrastinated doing?
*
If you could make a guess of what or who could help you with this issue, who or what would that be?
*
Please fill in all the blanks that describe your health practices.
When I start ___________ , I run out of motivation and go back to previous habits that are familiar, but don’t help me. For example, when I start exercising, my work schedule changes and I miss days of exercise.
*
I put off starting ____________, even though I know it would help my health.
*
Detoxification Questionnaire
Rate each of the following symptoms based on your typical health profile. Point Scale: 0 - Never or almost never have the symptom 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe. 3 - Frequently have it, effect is not severe. 4 - Frequently have it, effect is severe
Medical Symptoms Questionnaire (MSQ)
Head
Headaches
*
Please enter a number less than or equal to
4
.
Faintness
*
Please enter a number less than or equal to
4
.
Dizziness
*
Please enter a number less than or equal to
4
.
Insomnia
*
Please enter a number less than or equal to
4
.
Eyes
Watery, irritated, or itchy eyes
*
Please enter a number less than or equal to
4
.
Swollen, reddened, or sticky eyelids
*
Please enter a number less than or equal to
4
.
Bags or dark circle under eyes
*
Please enter a number less than or equal to
4
.
Blurred eye sight or tunnel vision
*
Please enter a number less than or equal to
4
.
Nose
Stuffy Nose
*
Please enter a number less than or equal to
4
.
Sinus Problems
*
Please enter a number less than or equal to
4
.
Hay Fever
*
Please enter a number less than or equal to
4
.
Sneezing attacks
*
Please enter a number less than or equal to
4
.
Excessive mucus formation
*
Please enter a number less than or equal to
4
.
Mouth/Throat
Chronic Coughing and Mucus Buildup
*
Please enter a number less than or equal to
4
.
Gagging, frequent need to clear throat
*
Please enter a number less than or equal to
4
.
Sore throat, hoarseness, loss of voice
*
Please enter a number less than or equal to
4
.
Swollen or discolored tongue, gums, lips
*
Please enter a number less than or equal to
4
.
Canker sores
*
Please enter a number less than or equal to
4
.
SKIN
Acne
*
Please enter a number less than or equal to
4
.
Hives, rashes, dry skin
*
Please enter a number less than or equal to
4
.
Hair loss
*
Please enter a number less than or equal to
4
.
Flushing, hot flashes
*
Please enter a number less than or equal to
4
.
Excessive sweating
*
Please enter a number less than or equal to
4
.
Heart
Chest pain or muscle tightness
*
Please enter a number less than or equal to
4
.
Irregular/skipped heartbeat
*
Please enter a number less than or equal to
4
.
Rapid or pounding heartbeat
*
Please enter a number less than or equal to
4
.
Lungs
Chest congestion
*
Please enter a number less than or equal to
4
.
Asthma, bronchitis
*
Please enter a number less than or equal to
4
.
Shortness of breath
*
Please enter a number less than or equal to
4
.
Difficulty breathing
*
Please enter a number less than or equal to
4
.
Digestive Track
Nausea, vomiting
*
Please enter a number less than or equal to
4
.
Diarrhea
*
Please enter a number less than or equal to
4
.
Constipation
*
Please enter a number less than or equal to
4
.
Bloated feeling
*
Please enter a number less than or equal to
4
.
Belching , passing gas
*
Please enter a number less than or equal to
4
.
Heartburn
*
Please enter a number less than or equal to
4
.
Intestinal/stomach pain
*
Please enter a number less than or equal to
4
.
Joint/Muscle
Pain or aches in joints
*
Please enter a number less than or equal to
4
.
Arthritis
*
Please enter a number less than or equal to
4
.
Limited movement
*
Please enter a number less than or equal to
4
.
Weakness or tiredness
*
Please enter a number less than or equal to
4
.
Pain or aches in muscles
*
Please enter a number less than or equal to
4
.
Weight
Binge eating/drinking
*
Please enter a number less than or equal to
4
.
Craving certain foods
*
Please enter a number less than or equal to
4
.
Excessive weight
*
Please enter a number less than or equal to
4
.
Water retention
*
Please enter a number less than or equal to
4
.
Underweight
*
Please enter a number less than or equal to
4
.
Compulsive eating
*
Please enter a number less than or equal to
4
.
Energy Activity
Fatigue, sluggishness
*
Please enter a number less than or equal to
4
.
Apathy, lethargy
*
Please enter a number less than or equal to
4
.
Hyperactivity
*
Please enter a number less than or equal to
4
.
Restlessness
*
Please enter a number less than or equal to
4
.
Mind
Poor memory
*
Please enter a number less than or equal to
4
.
Confusion
*
Please enter a number less than or equal to
4
.
Indecisiveness
*
Please enter a number less than or equal to
4
.
Stuttering or stammering
*
Please enter a number less than or equal to
4
.
Siurred speech
*
Please enter a number less than or equal to
4
.
Learning disabilities
*
Please enter a number less than or equal to
4
.
Poor concentration
*
Please enter a number less than or equal to
4
.
Poor physical coordination
*
Please enter a number less than or equal to
4
.
Emotions
Mood swings
*
Please enter a number less than or equal to
4
.
Anxiety, fear, nervousness
*
Please enter a number less than or equal to
4
.
Anger/Aggressiveness
*
Please enter a number less than or equal to
4
.
Depression
*
Please enter a number less than or equal to
4
.
Other
Frequent illness
*
Please enter a number less than or equal to
4
.
Frequent/Urgent urination
*
Please enter a number less than or equal to
4
.
Genital itch or discharge
*
Please enter a number less than or equal to
4
.
II. Xenobiotic Tolerability Test (XTT)
Weight
Are you presently using prescription drugs?
*
Yes
No
If yes, how many are you currently taking?
If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them:
*
Experience side effects, drug(s) is (are) efficacious at lowered dose(s) (3 pts.)
Experience side effects, drug(s) is (are) efficacious at usual dose(s) (2 pts.)
Experience no side effects, drug(s) is (are) usually not efficacious (2 pts.)
Experience no side effects, drug(s) is (are) usually efficacious (0 pts.)
Do you currently use or within the last 6 months had you regularly used tobacco products?
*
Yes (2 pts.)
No (0 pts.)
Do you have strong negative reactions to caffeine or caffeine containing products?
*
Yes (1 pt)
No (0 pt)
Don't know (0 pt.)
Do you commonly experience "brain fog", fatigue, or drowsiness?
*
Yes (1 pt)
No (0 pts.)
Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
*
Yes (1 pt)
No (0 pt)
Don't know (0 pt)
Do you have a personal history of
*
Chronic fatigue syndrome (5 pts)
Multiple chemical sensitivity (5 pts)
Fibromyalgia (3 pts)
Parkinson's type symptoms (3 pts)
Alcohol or chemical dependence (2 pts)
Asthma (1 pt.)
None of the above
Do you feel ill after you consume even small amounts of alcohol?
*
Yes (1 pt)
No (0 pts.)
Don't know (0 pts)
Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
*
Yes (1 pt)
No (0 pts.)
Do you have an adverse or allergic reaction when you consume sulfite containing oods such as wine, dried fruit, salad bar vegetables, etc?
*
Yes (1 pt)
No (0 pts.)
Don't know (0 pts.)
Alkalizing Assessment
Do you have a history or currently have kidney dysfunction?
*
Yes
No
Are you currently on diuretics or blood pressure medication?
*
Yes
No
DASS Questionnaire
Please read each statement and select a number, 0 1 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time.
I found myself getting upset by quite trivial things
*
0
1
2
3
I was aware of dryness of my mouth
*
0
1
2
3
I couldn't seem to experience any positive feeling at all
*
0
1
2
3
I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)
*
0
1
2
3
I just couldn't seem to get going
*
0
1
2
3
I tended to over-react to situations.
*
0
1
2
3
I had a feeling of shakiness (eg, legs going to give way)
*
0
1
2
3
I found it difficult to relax
*
0
1
2
3
I found myself in situations that made me so anxious I was most relieved when they eneded.
*
0
1
2
3
I felt that I had nothing to look forward to
*
0
1
2
3
I found myself getting upset rather easily
*
0
1
2
3
I felt that I was using a lot of nervous energy
*
0
1
2
3
I felt sad and depressed
*
0
1
2
3
I found myself getting impatient when I was delayed in any way (eg, lifts, traffic lights, being kept waiting)
*
0
1
2
3
I had a feeling of faintness
*
0
1
2
3
I felt that I had lost interest in just about everything
*
0
1
2
3
I felt I wasn't worth much as a person
*
0
1
2
3
I felt that I was rather touchy
*
0
1
2
3
I perspired noticeably in the absence of high temperatures or physical reason
*
0
1
2
3
I felt that life wasn't worthwhile
*
0
1
2
3
I found it hard to wind down
*
0
1
2
3
I had difficulty in swallowing
*
0
1
2
3
I couldn't seem to get any enjoyment out of the things I did
*
0
1
2
3
I was aware of the action of my heart in the absence of physical exertion (sense of heart rate increase, heart missing a beat)
*
0
1
2
3
I felt down-hearted and blue
*
0
1
2
3
I found that I was very irritable
*
0
1
2
3
I felt I was close to panic
*
0
1
2
3
I found it hard to calm down after something upset me
*
0
1
2
3
I feared that I would be "thrown" by some trivial but unfamiliar task
*
0
1
2
3
I was unable to become enthusiastic about anything
*
0
1
2
3
I found it difficult to tolerate interruptions to what I was doing
*
0
1
2
3
I was in a state of nervous tension
*
0
1
2
3
I felt I was pretty worthless
*
0
1
2
3
I was intolerant of anything that kept me from getting on with what I was doing
*
0
1
2
3
I felt terrified
*
0
1
2
3
I could see nothing in the future to be hopeful about
*
0
1
2
3
I felt that life was meaningless
*
0
1
2
3
I found myself getting agitated
*
0
1
2
3
I was worried about situations in which I might panic and make a fool of myself
*
0
1
2
3
I experienced trembling (eg, in the hands)
*
0
1
2
3
I found it difficult to work up the initiative to do things
*
0
1
2
3
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*
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