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