Patient Intake Form

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 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 Country

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.

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.

Consent*
I agree to the Patient Information Practices, Office Policies, and Privacy Statements
Patient Information and Office Policies

And

Information Practices and Privacy Statement
Add me to your weekly newsletter list. (optional)
- Yes, keep me informed of new products and services

New Patient Intake Form

Step 1 of 22

Personal Health History

FUNCTIONAL DIAGNOSTIC MEDICINE QUESTIONAIRE

FUNCTIONAL DIAGNOSTIC MEDICINE QUESTIONNAIRE

FEMALE MEDICAL HISTORY (FOR WOMEN ONLY)

GYNECOLOGYCAL HISTORY

MALE MEDICAL HISTORY (FOR MEN ONLY)

PAST MEDICAL AND FAMILY HISTORY

SOCIAL HISTORY

Mental Health

DIET AND GASTROINTESTINAL HEALTH

OVERALL IMMUNE AND INFLAMMATORY BALANCE

ENVIRONMENTAL FACTORS IN HEALTH

HEALTH HABITS AND PERSONAL SAFETY

Diet

Caffeine

Alcohol

Tobacco

Sex

Stress / Coping

Daily stressors: Rate in a scale from 1 - 10 (1 not stressful – 10 very stressful)

READINESS / ASSESSMENT

Rate on a scale of: 5 (very confident) to 1 (not confident)

Rate on a scale of: 5 (very supportive) to 1 (not supportive at all)

Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact)

Health And Wellness

STEP ONE What Is Your Current “Health Blueprint”?

Please fill in all the blanks that describe your health practices.

Detoxification Questionnaire

Medical Symptoms Questionnaire (MSQ)

Head

Eyes

Nose

Mouth/Throat

SKIN

Heart

Lungs

Digestive Track

Joint/Muscle

Weight

Energy Activity

Mind

Emotions

Other

II. Xenobiotic Tolerability Test (XTT)

Weight

Alkalizing Assessment

DASS Questionnaire

Fill out a quick Health and Wellness Questionnaire.

Get a Free 20 Minute Consultation.