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INITIAL PATIENT HISTORY AND PROFILE
Name ______________________________________________________________Date ____________________
Home Phone (_______)______________________ Cell Phone (_______)________________________
Address___________________________________ City ______________State __________Zip Code ______________
Social Security Number_________________________________________________________________________
Date of Birth_________________ Email Address____________________________________________________
Height _______________ Weight ________________
Please briefly describe your health problems:_________________________________________________________
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When was the last time you really felt good (date)? _____________. Were you healthy as a child? _______________
If not please list health problems you had as a child: ____________________________________________________
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What caused your PRESENT illness?
Significant Event at Onset: Health Problem, Family Problem, Job Stressors, Surgery, Accident, not sure?
Please briefly explain:________________________________________________________________________________
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Have you been diagnosed with Fibromyalgia or Chronic Fatigue Syndrome? ____YES ____NO If yes, which one?_____________
Date of Diagnosis______ Who Diagnosed you?__________________________________
What type of doctor made diagnosis (family doctor, rheumatologist, OBGYN, orthopedic doctor, etc.)?___________________________
What makes your health problems worse? Stress, weather changes, poor sleep, exertion, etc: ____________________________________
SLEEP
Do you have trouble falling asleep? ___Yes ___No
Do you have trouble Staying Asleep? ___Yes ___No
When did you first start having trouble sleeping (months, years)? _____________
NEUROTRANSMITTERS
What over the counter or prescription medications have you taken for sleep?
__ Ambien ____ Zanaflex_____ Trazadone______ Sonata_________ Tylenol P.M. ___ Elavil ___ Neurontin
___Doxepin____Flexeril_____Xanax_____Klonopin_____Ativan_____Melatonin_____5HTP ___ Benadryl
____Others? Please list here___________________________________________________________________
Are you taking anti-depressants? ___Yes ___No Which ones? _______________________________________
Have you taken any anti-depressants in the past? ___Yes___ No
Which ones? Prozac_____Paxil_____Celexa____Lexapro_____Wellbutrin___Effexor____Zoloft____
Where they helpful? Please describe (didn’t help, had side –effects, stopped working, etc.)
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Do you crave carbohydrates or sugar? ___Yes ___No
Do you have normal, daily bowel movements (at least one bowel movement a day)? ___Yes ____No
If no - Do you have loose bowels (diarrhea), constipation, or both? ________________________________
Have you been diagnosed with Irritable Bowel Syndrome (IBS)? ____Yes ____No
What other medications are you taking? Please list here-
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IMMUNE FUNCTION
DO YOU HAVE PROBLEMS WITH: Please those that apply.
____ Chronic Sinus Congestion ____ Chronic Sinus Infections (2 or more a year) ___ Chronic Sore Throats
____Chronic Colds or Flu infections each year ____Chronic Upper Respiratory Infections (Bronchitis, Pneumonia)
LIVER FUNCTION
Have you ever had elevated or high liver enzymes on laboratory blood work? __Yes __ No __Not Sure
Do you have any funny reactions if you drink alcohol (little goes a long way, can’t drink red wine, etc.)?
If so please describe _________________________________________________________________________
Do you have any problems eating raw onions? ____ Yes ____No
The day after eating asparagus do you get a very strong odor when urinating (the next day?) ____________
Do you have hepatitis? ___Yes ___ No Do you have a fatty liver? __ Yes __ No
Do you have funny reactions to medications? ___Yes ___No
Do strong odors (gasoline, smoke, cleaning supplies, perfume, etc.) bother you? ___Yes ___No
ADRENAL FUNCTION
If you skip a meal do you feel bad (have headaches, become irritable, get jittery, tired, etc.) ___ Yes __No
Do you have low blood pressure? ___Yes ___ No __ Don’t Know
Do you crave salty foods? ___Yes ___No
Does increased stress or stressful situations make your symptoms worse? ___Yes ____No
How's your energy level? Choose 1 to 5, with 5 being the best. ______
How is your concentration and memory on a scale of 1-5, with 5 being best? ________
How do you feel in the morning? ____Refreshed_____ Hung over_____ Exhausted_______ Nauseated_____ Achy All Over
Are you hungry in the morning? ___Yes ___No
DIGESTION
How is your digestion? Bloating ___Yes ___No Gas ___Yes ___No Indigestion ___Yes ___No
Are there certain foods that give you problems (sugar, spicy foods, fruits, meats, fats, dairy, etc.)?
Please list: ________________________________________________________________________________________
DIET - EATING HABITS
What do you eat for breakfast? Please (honestly) describe here: ________________________________________________________
What do you eat for Lunch? _____________________________________________________________________________________
What do you eat for dinner? _____________________________________________________________________________________
What are your usually snack foods (popcorn, ice cream, cookies, potato chips, candies)? Please be honest and specific-
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Do you drink coffee? If so how many cups a day and when ____________________________________________________________
Do you drink sodas? If so how many and when? ____________________________________________________________________
Do you drink tea? If so how many glasses and when? ________________________________________________________________
PAIN
Where do you have pain? ____Joint ____Muscle ____Neck ____Shoulder ____ Mid Back ____Low Back ___Chest
___ Hips____ Arms ____Back of Legs ____ Front of legs ___Knees ____ Feet____ Ankles_____ Hands ___Fingers___ Head
HISTORY
Please place a check mark by any that apply below.
Do you ever have -
HEENT: ____Headaches ____Vision Problems ____Frequent Colds/Sore Throats
____ Dizziness ____ Hearing Problems
Chemical Sensitivities/Allergies: _____________________________________
CVS: ____Chest Pain ____ Palpitations ____High Cholesterol ____ High Blood Pressure
LUNGS: ____Coughing ____Wheezing ____Breathing Problems ___ Frequent Respiratory Infections
GI: ____Swallowing Problems ____Stomach Pains ____Nausea ____Vomiting
____Diarrhea ____Constipation ____Digestive Difficulties
Food allergies __Yes ___No
GU: ____Urinary Frequency ____Urinary Hesitancy ____Irregular Periods ____ Decreased Sex Drive
SKIN: ____Rashes ____Dry Skin ____Fungus Infections ____Eczema ____Psoriasis
Social History: Do You Smoke? ____Yes ____No
Family History: ____Cancer ____Diverticulitis ____Thyroid ____Heart Disease____ Stroke ____Diabetes
____High Cholesterol
INTESTINAL DYSBIOSIS
Have you ever been on long term (more than 2 weeks) antibiotic therapy? ___ Yes____ No
Have you ever had vaginal yeast infections? __Yes __No
If yes, when was last infection? ________________
Do you have chronic vaginal yeast infections (more than 2 a year)? ___Yes __No
Are you bothered by memory or concentration problems? Do you sometimes feel spaced-out? ___
Do you feel “sick all over”, yet in spite of visits to different physicians, the causes haven’t been found? ______
Have you been pregnant TWO or more times? ______________
Have you taken birth control pills? _______ for more than 2 years?_____ for more than 1 year? _________6 months to 1 year?___________
Are your symptoms worse on damp, muggy days or in moldy places? ____________
Do you ever have itchy ears? __Yes __No Itchy nose? __Yes __No Rectal Itching? ____Yes __No
Do you crave Sugar? ____ Yes ___No Does eating sugar make your symptoms worse? __Yes __No
Do you have rectal itching after eating sugar, fruit, or a lot of starches? ___Yes ___No
Have you EVER been on long term (weeks) steroid therapy (prednisone, cortisone)? _____Yes ___No
Have you EVER been on long term (month or more) non-steroidal anti-inflammatory medications (Vioxx, Celebrex, Naprosyn, Advil, Bextra, Mobic, etc.)? __Yes __No
YEAST QUESTIONNAIRE
Please mark your symptoms as follows: MI-mild M-moderate S-severe
* Feeling of being “drained” _____
* Abdominal pain _____
* Constipation and/or diarrhea _____
* Bloating, belching or intestinal gas_____
* Indigestion or heartburn _____
* Prostatitis_____
* Endometriosis or infertility _____
* Cramps and/or menstrual irregularities ______
* Premenstrual tension (PMS) _____
* Sore throat _____
* Recurrent sinus infections _____
* Chronic hives _____
* Cough or recurrent bronchitis _____
* Nasal congestion or postnasal drip _____
* Nasal itching _____
* Eczema
* Psoriasis ______
* Cystitis or interstitial cystitis ________
* Pressure in the ears_____
* Troublesome vaginal burning, itching or discharge _____
* Rectal itching _____
* Dry mouth or Throat _____
* Mouth rashes, Including “ white” tongue ____
* Bad breath _____
* Foot, hair or body odor not relieved by washing _____
* Wheezing or shortness of breath _____
* Urinary frequency or urgency _____
* Burning on urination _____
* Burning or tearing eyes _____
THYROID
Symptom Checklist
___ Fatigue ___ High Cholesterol
___ Headaches ___ Cold hands/feet
___ Migraines ___ Changes in skin pigmentation
___ PMS ___ Changes in skin pigmentation
___ Irritability ___ Irregular periods
___ Fluid retention ___ Severe menstrual cramps
___ Dry hair ___ Low blood pressure
___ Dry skin ___ Frequent colds and sore throats
___ Hair loss ___ Heat and/or cold intolerance
___ Depression ___ Lightheadedness
___ Decreased memory ___ Ringing in the ears
___ Decreased concentration ___ Infertility
___ Decreased sex drive ___ Asthma
___ Unhealthy nails ___ Low motivation
___ Constipation ___ Frequent infections
___ Irritable Bowel Syndrome ___ Allergies
___ Inappropriate weight gain ___ Falling asleep during the day
___ Hypoglycemia
PARASITE CHECKLIST
____ Have you traveled outside the United States?
_____Do you have foul smelling stools?
_____Do you experience any stomach bloating, gas, or pain?
____ Any rectal itching?
_____Unexpected weight loss with increased appetite?
_____Food allergies that continue to get worse despite treatment.
_____Do you feel hungry all the time?
_____Have you been diagnosed with irritable bowel syndrome?
_____What about inflammatory bowel disease?
_____Do you have sore mouth and gums?
_____Do you experience chronic low back pain that’s unresponsive to treatment?
_____Do you have digestive disturbances?
_____Do you grind your teeth at night?
_____Do you own a dog, cat or other pet? Or are frequently around animals?
BRAIN FUNCTION QUESTIONNAIRE
The "O" Group
Do ANY of these apply to your present feelings?
* Your life seems incomplete.
* You feel shy with all but your close friends.
* You have feelings of insecurity.
* You often feel unequal to others.
* When things go right you sometimes feel undeserving.
* You feel something is missing in your life.
* You occasionally feel a low self worth or esteem.
* You feel inadequate as a person.
* You frequently feel fearful when there is nothing to fear.
The "G" Group
Please note the items which apply to your present feelings.
* You often feel anxious for no reason.
* You sometimes feel "free floating" anxiety.
* You frequently feel "edgy" and its difficult relax.
* You often feel a "knot" in your stomach.
* Falling asleep is sometimes difficult.
* It’s hard to turn your mind off when you want to relax.
* You occasionally experience feelings of panic for no reason.
* You often use alcohol or other sedatives to calm down.
The "D" Group
Please note the items which apply to your present feelings.
* You lack pleasure in life.
* You feel there are no real rewards in life.
* You have unexplained lack of concern for others, even loved ones.
* You experience decreased parental feelings.
* Life seems less "colorful" or "flavorful."
* Things that used to be "fun" aren’t any longer enjoyable.
* You have become a less spiritual or socially concerned person.
The "N" Group
Please note the items which apply to your present feelings.
* You suffer from a lack of energy.
* You often find it difficult to "get going."
* You Suffer From Decreased Drive.
* You Often Start Projects and Then Don't Finish Them.
* You Frequently Feel A Need To Sleep Or "Hibernate."
* You Feel Depressed A Good Deal Of The Time.
* You Occasionally Feel Paranoid.
* Your Survival Seems Threatened.
* You Are Bored A Great Deal Of The Time.
The "S" Group
Please note the items which apply to your present feelings.
* It’s hard for you to go to sleep.
* You Can't Stay Asleep.
* You Often Find Yourself Irritable.
* You’re Emotions Often Lack Rationality.
* You Occasionally Experience Unexplained Tears.
* Noise bothers You More than It Used To. It seems louder than normal.
* You "Flare Up" At Others More Easily Than You Used To.
* You Experience Unprovoked Anger.
* You Feel Depressed Much Of The Time.
* You Find You Are More Susceptible To Pain.
* You Prefer To Be Left Alone.
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