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Print version Personal History Name: Age: Birth Date: Height: Address: Weight: Home Phone: Occupation: Work Phone: Waist (inches): Fax: Hip size (inches): E-mail: Gender: Male Female Marital Status: Married Single Widowed Divorced Main Residence: City Suburban Rural What personal goals would you like to achieve? Family History Check all that apply Diabetes Stroke Cancer Arthritis High Blood Pressure Asthma/Emphysema Heart Disease Mental Illness/Dementia Genetic Disorders Other: Medical History Hospitalization: Give reasons and dates Surgeries: Give types and dates Allergies: Include Medications and Environmental Prescription medication: Over-the-counter medications: Vitamins and/or natural supplements: Personal Habits Choose best answer Alcohol (drinks per week): None 1-7 8-14 15-21 More than 21 Cigarettes (packs per day): Less than .5 .5-1 1-1.5 1.5-2 More than 2 Recreational drugs: No Yes, if so, what type? Caffeine (cups per day): None 1-2 3-4 5-6 More than 6 Do you wear a seatbelt? Yes No Do you have sleeping problems? (Falling asleep, continuity disturbances) Yes No Do you exercise 3 or more times per week for 20 consecutive minutes? Yes, if yes, list exercise No Do you drink eight 8oz glasses of filtered or bottled water per day? Yes No Environmental risks or toxic exposures: Check all that apply Dust/Inhaled particles Chemicals/Pesticides Radiation Hazmat Fumes Excessive Household Cleaners FOR MALES ONLY Do you experience urinary problems? Check all that apply No Incomplete Emptying of Bladder Weak Stream Frequency of Urination Penile Discharge Difficulty Initiating Stream Painful Urination Do you have a regular sexual partner? Yes No Do you experience erectile dysfunction? Yes No Have you had a sexually transmitted disease? Check all that apply No Gonorrhea Syphilis Urethritis Herpes Other FOR FEMALES ONLY Is your menstrual cycle regular? Yes No Do you experience heavy bleeding or severe pain? Yes No Do you perform a self breast exam every month? Yes No Are you pregnant? Yes No Do you want to become pregnant? Yes No Was your last Pap smear normal? Yes No Not Done Was your last mammogram normal? Yes No Not Done Method of birth control Check all that apply None Barrier (diaphragm or condom) Oral Contraceptives I.U.D. Rythm method Norplant or DepoProvera injection Other Have you had a sexually transmitted disease? Check all that apply No Gonorrhea Syphilis Chlamydia Herpes Other Do you have a regular sexual partner? Yes No Do you experience frequent urinary tract infections? Yes No General Health Information How would you describe your general daily mood? Check all that apply Content Frustrated Sad/Depressed Happy Anxious/Panicked Angry Hopeless Energetic Fatigued Other Apathetic How would you rate your stress level? None Minimal Moderate High Unbearable How would you describe your general health? Very Poor Poor Adequate Good Great How often do you use antibiotics per year? Never/Rarely 2-4 5-7 8-10 11-13 More Than 13 How often do you use pain medication per week? (Includes aspirin, ibuprofen, naproxyn, tylenol, and prescription pain medications) Never/Rarely 2-4 5-7 8-10 11-13 More Than 13 List what medications you use: Dietary Habits How many servings of the following do you eat per week? Water (8oz. glasses): None 1-3 4-6 7-10 More Than 10 Fresh Fruit (NOT canned): None 1-6 7-14 15-21 22-28 More Than 28 Fresh green vegetables: None 1-6 7-14 15-21 22-28 More Than 28 Meats/Dairy: None 1-6 7-14 15-21 22-28 More Than 28 Pasta/Bread/Processed Starches/Processed Cereals/Potatoes: None 1-6 7-14 15-21 22-28 More Than 28 Grains (Unprocessed cereals like oatmeal, and barley, BROWN rice): None 1-6 7-14 15-21 22-28 More Than 28 Sugars (candy, cakes, etc.): None 1-6 7-14 15-21 22-28 More Than 28 Fried food/Fast food: None 1-6 7-14 15-21 22-28 More Than 28 Do you eat organic food? Yes, if yes, what percent of your diet is organic? No What is your salt intake? None Small Moderate Large Symptoms (point scale) 0 - never or almost never have the symptom 1 - occaisonally have it, the effect is not severe 2 - occasionally have it, the effect is severe 3 - frequently have it, the effect is not severe 4 - frequently have it, the effect is severe 0 1 2 3 4 Headaches 0 1 2 3 4 Dizziness 0 1 2 3 4 Fainting/Loss of Consciousness 0 1 2 3 4 Itchy/Watery Eyes 0 1 2 3 4 Visual Changes 0 1 2 3 4 Hayfever/Seasonal allergies 0 1 2 3 4 Hearing Problems (loss, ringing in ears) 0 1 2 3 4 Sinus Problems 0 1 2 3 4 Chronic Coughing or Wheezing 0 1 2 3 4 Difficulty Breathing 0 1 2 3 4 Difficulty Swallowing 0 1 2 3 4 Throat/Vocal Problems 0 1 2 3 4 Indigestion/Hearburn 0 1 2 3 4 Acne 0 1 2 3 4 Hives, Rashes, Eczema, or Psoriasis 0 1 2 3 4 Hair Loss 0 1 2 3 4 Chest Pain 0 1 2 3 4 Palpitations or Punding Heartbeat 0 1 2 3 4 Persistant Abdominal Pain 0 1 2 3 4 Persistent Nausea or Vomiting 0 1 2 3 4 Urinary Problems, Infections, or Dysfunction 0 1 2 3 4 Genital Itch or Discharge 0 1 2 3 4 Diarrhea 0 1 2 3 4 Constipation 0 1 2 3 4 Bloody or Black/Tarry Stools 0 1 2 3 4 Colitis (inluding Crohns disease, Irritable Bowel disease, and Diverticular disease) 0 1 2 3 4 Hemorrhoids 0 1 2 3 4 Sexual Dysfunction 0 1 2 3 4 Joint Pain/Arthritis 0 1 2 3 4 Chronic Fatigue 0 1 2 3 4 Poor Memory or Concentration 0 1 2 3 4 Mood Swings 0 1 2 3 4 Anxiety, Fear, or Nervousness 0 1 2 3 4 Anger, Irrirability, Impatience, or Aggressiveness 0 1 2 3 4 Depression 0 1 2 3 4 Speech Difficulties 0 1 2 3 4 Frequent Illness 0 1 2 3 4 Unintentional Weight Loss 0 1 2 3 4 Weight Gain 0 1 2 3 4 Other 0 1 2 3 4 Other

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