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Patient Intake Form: Part #3
Name
_________________________________________________ Sex ____ Age ______ Date
_____/____/_____ Medications currently using
_______________________________________________________________________________ Supplements
currently taking
_______________________________________________________________________________ Five
Most Significant Health Problems
_______________________________________________________________________________ _______________________________________________________________________________ Circle
any of the following item you consume:
Instructions:
Read the following symptoms and fill in the number that
applies:
0 = Do not have the symptom, the symptom does not apply
1 = It is a minor symptom or it rarely
occurs
2 = It is a moderate symptom or it occasionally
occurs
3 = It is a significant symptom or it frequently
occurs
4 = It is a severe symptom or you are aware of it almost
constantly Rate
the severity or frequency of the symptom from 0 to 4. How significant is
the symptom? How true is the
statement—0 means not at all, 4 means extremely true. Where the question
is answered by yes or no, circle Y or N. 1.
_____ Fingernails
chip, peel or break easily 2.
_____ Belching
or gas within 1 hr. of a meal 3.
_____ Distaste
for meat (not a vegetarian for moral other or other reasons)
4.
_____ Fewer
than one bowel movement per day 5.
_____ Stools
hard or difficult to pass 6.
_____ Bloating
after eating 7. _____ Only specific foods cause
bloating 8.
_____ Sleepy
after eating 9.
_____ Sensitive
to smoke 10.
_____ Feeling
“wired” or jittery if drinking coffee 11.
_____ Pain
between the shoulder blades 12.
_____ Bizarre,
vivid or nightmarish dreams 13.
_____ Metallic
taste in the mouth 14.
_____ Bitter
taste in mouth, especially after meals 15.
_____ Become
sick after drinking wine (as opposed to other alcoholic beverages)
16.
_____ Wake
up without remembering dreams 17.
_____ Bothered
if eating food with monosodium glutamate (MSG) 18.
_____ Become
intoxicated easily if drinking alcohol 19.
_____ Severe
hangovers after drinking alcohol 20.
_____ Trouble
tolerating greasy foods 21.
_____ Trouble
tolerating aspartame (Nutrasweet) 22.
_____ Frequent
fevers 23.
_____ Trouble
tolerating garlic or onions 24.
_____ Gallbladder
attacks (past or present) 25.
_____ Urine
has a strong odor 26.
_____ Dry
flaky skin or dandruff 27.
_____ Sensitive
to chemicals (perfume, insecticides, exhaust fumes) 28.
_____ Hemorrhoids
or varicose veins 29.
_____ Take
over the counter pain medication 30. Y N Aspirin
is an effective pain reliever 31.
_____ Sweat
a lot 32.
_____ Sweat
at night 33.
_____ Feet
have a strong odor or sweat easily 34.
_____ Lower
bowel gas 35.
_____ Alternating
constipation/diarrhea 36.
_____ Nausea
37.
_____ Epigastric
( top of stomach) burning or gastric reflux
38.
_____ Patches
of dry skin, eczema or psoriasis 39.
_____ Hair
breaks or falls out easily 40.
_____ Anus
itches 41.
_____ Coated
tongue 42.
_____ Lactose
intolerant 43.
_____ Colitis,
irritable bowel or Crohn’s disease 44.
_____ Crave
sugar 45.
_____ Eat
a dessert with sugar, donut, soft drink, ice cream etc. (1 = 1x/week; 2 =
2-3x/week; 3 = daily or almost daily; 4 = more than 1x/day)
46.
_____ Crave
bread or noodles 47.
_____ Eat
refined white flour products (French, Italian or other white bread,
bagels, pasta etc.) [1= 1x/week; 2 = 2-3x/week; 3 = daily or almost daily;
4 = more than 1x/day]
48.
_____ Are
there any foods that you feel that you would not want to give up? (Think
of foods that you eat every day like bread, cheese etc.)
49.
_____ Have
you taken tetracyclines (Sumycin, Panmycin Vibramycin, Minocin) for acne?
[1 = 1 mo.; 2 = 2 mo.; 3 = 3 mo.;
4 = 4 mo. or longer]
50.
_____ Have
you taken broad-spectrum antibiotics for urinary, respiratory or other
infection? ( 1 = 1 course < 2 mo.; 2 = 1 course 2 mo. or longer; 3 = 2x in a single year; 4 = more
than 2x in a single year) 51.
_____ Hay
fever or seasonal allergies 52.
_____ Feel
worse when in a moldy or musty place 53.
_____ Sinusitis
(nose stuffy, sinus headaches or
sinus infections) 54.
_____ Runny
or drippy nose 55.
_____ Catch
colds at the beginning of winter 56.
_____ Migraine
headaches 57.
_____ Binge
eating or uncontrolled eating 58.
_____ Asthma,
wheezing or difficulty breathing 59.
_____ Crave
coffee or sugar in the afternoon 60.
_____ Afternoon
headaches 61.
_____ Fatigue
that is relieved by eating 62.
_____ Shaky,
headachy, or tired when meals are delayed 63.
_____ Family
history of diabetes (1 = distant relative; 2 = 1 or 2 direct
relatives; 3 = 3 or 4 direct
relatives; 4 = more than 4 direct relatives) 64.
_____ Frequent
thirst 65.
_____ Cuts
take a long time to heal 66.
_____ Frequent
urination 67.
_____ Frequent
infections 68.
_____ Numbness
or tingling in the extremities 69.
_____ Fatigue
70.
_____ Cry,
become teary or sad for no reason 71.
_____ Ankles
swell 72.
_____ Become
cold easily or when others are not 73.
_____ Depression
74.
_____ If
#73 is a symptom of yours, can you characterize your depression as feeling
“low” with a strong desire to sleep, sleeping a lot and having trouble
getting out of bed
75.
_____ If
#73 is a symptom, can you characterize your depression as feeling
agitated, anxious or having difficulty falling and staying asleep
76.
_____ Lack
of motivation (function from day to day but lacking initiative)
77.
_____ Brittle,
coarse hair 78.
_____ Difficulty
losing weight 79.
_____ Frequent
colds or the flu 80.
_____ Frequent
diets (reducing food intake) (1=1 or 2; 2=3 or 4; 3 = 5 or 6; 4 = 7 or
more) 81.
_____ Crave
salt or salty foods 82.
_____ Crave
greasy or fatty foods 83.
_____ Pain
on the inside (medial) knee or on one side of the low back
84.
_____ Become
dizzy when standing up suddenly 85.
_____ Trouble
getting out of bed in the morning 86.
_____ Tend
to be a “night” person 87.
_____ Tendency
to worry 88.
_____ Tend
to be calm on the outside, troubled inside 89.
_____ Changed
marital status (1=w/in 2
years; 2= w/in 1 year; 3= w/in 6 mos.; 4 = w/in 3 mos.)
90.
_____ Death
of a loved one. (1=w/in 2 years; 2= w/in 1 year; 3= w/in 6 mos.; 4 = w/in 3 mos.)
91.
_____ Changed
jobs, lost a job or started a new job. (1=w/in 2 years; 2= w/in 1
year; 3= w/in 6 mos.; 4 =
w/in 3 mos.) 92.
_____ How
many hours do your work each week? (1= 45 or less; 2= 45-50; 3= 50-55; 4=more than 55) 93.
_____ Keyed
up, trouble calming down. 94.
_____ Fall
asleep only to wake up after a few hours and have trouble falling back to
sleep 95.
_____ Difficulty
falling asleep 96.
_____ Feelings
of insecurity 97.
_____ Heart
races or palpitates 98.
_____ Clench
or grind teeth 99.
_____ Jaw
clicks, pops, locks or makes noise 100.
_____ Tension
headaches (base of skull) 101.
_____ Headaches
when hot or out in the sun 102.
_____ Get
up at night to urinate 103.
_____ Decreased
ability to taste or smell 104.
_____ Get
hives 105.
_____ Acne
106.
_____ Undigested
food in stool 107.
_____ Taken
birth control pills (1= 6 mos. or less ; 2= 1 yr. or less; 3= 1-2 yrs.; 4=
more than 2 yrs.) 108.
_____ Feel
spacey or unreal
109.
_____ Rehabilitated
or done construction in a house built before 1970 (1= yes, but didn’t live
there during work; 2= lived there when the work was done; 3= rehabbed more
than 1; 4= lived in more than
1 house that’s been rehabbed) 110.
_____ Fungus
or yeast infections
111.
_____ Exposure
to diesel fumes 112.
_____ Do
you smoke , how many pack-years (number of years times the number of packs
per day)? [1=2 or less; 2=3-5;
3=7-10 and 4= more than 10 pack-years] 113.
_____ Did
you quit smoking (1= more than 10 yrs ago; 2= 5-10 yrs.; 3=1-5 yrs.; 4=
less than 1yr) 114.
_____ How
many alcoholic beverages each week? (1= 1-7; 2= 8-14; 3= 14-21; 4= more
than 21 alcoholic beverages per week) 115. Y N Are
you a recovering alcoholic? 116. Y N History
of anorexia or
bulimia 117.
_____ How
many mercury (silver) fillings (1= 1-2; 2= 3-5; 3= 6-7; 4= more than 7
fillings) 118.
_____ Have
you taken shark cartilage? (mark 1 point for every 3 months on the
supplement) 119. Y N Diagnosed
with chronic fatigue syndrome or fibromyalgia
120.
_____ Pain
or swelling in the joints 121.
_____ Muscles
become easily fatigued 122.
_____ Anemia
that is unresponsive to iron 123.
_____ Greasy
or shiny stools 124.
_____ Clay-colored
stools 125.
_____ Stomach
upset by taking vitamins 126.
_____ Hands
tremble 127.
_____ Calves
cramp at night 128.
_____ Legs
cramp after walking, better after rest 129.
_____ Undigested
fat in stool 130.
_____ (Women)
Anxiety, irritability, emotional instability related to menstrual cycle
131.
_____ (Women)
Depression during period 132.
_____ (Women)
Weight gain greater than 3 pounds and/or abdominal bloating associated
with cycle 133.
_____ (Women) Breast tenderness, soreness or
swelling associated with cycle 134.
_____ (Women)
Excess menstrual flow 135.
_____ (Women)
Sugar, chocolate, or carbohydrate craving associated with cycle
136.
_____ Dark
circles under the eyes 137.
_____ Sense
of fullness after meals 138.
_____ Do
not feel like eating breakfast 139.
_____ Feel
better if you don’t eat 140.
_____ Black
or tarry stools 141.
_____ Pain
under right side of ribcage 142.
_____ Itchy
skin (maybe worse at night) 143.
_____ Cold
sores, fever blisters or Herpes lesions 144.
_____ Sunburn
easily or get “sun poisoning” 145.
_____ Cough
that produces mucus 146.
_____ Bruise
easily 147.
_____ Frequent
infections (ear, bladder, lung etc.) 148.
_____ Eyes
sensitive to bright light 149.
_____ Exercise
makes you feel worse 150.
_____ Blush
or face turns red for no reason 151.
_____ Pain
in chest, left arm or left side of neck 152.
_____ Sigh
frequently, air hunger or trouble catching breath 153.
_____ Fluid
retention 154.
_____ (Men)
Dribble after voiding urine 155.
_____ (Men)
Frequent urination or urgency to urinate 156.
_____ (Men)
Interruption of the stream during urination 157.
_____ Pain
or burning when urinating 158.
_____ Bloody,
cloudy and/or darkened urine 159.
_____ Decreased
libido 160.
_____ Decreased
scalp hair (not pattern baldness) 161.
_____ Increased
body hair 162. Y N Under
4’ 10” tall 163. Y N Over
6’ 6”
tall 164. Y N Early
sexual development 165.
_____ Brittle
hair that breaks easily
166.
_____ Exercise
(1= daily; 2= 4x/week or more; 3= 1-3x/week; 4= 1x/week or less)
167. Y N (Women)
Irregular (non-cancerous) cells found on a PAP smear 168. Y N Have
you ever had polyps? 169. Y N Use
of antidepressant medication? 170. Y N Have
the drugs (in #169) helped?
171.
_____ Anxiety
172. Y N Use
of anti-anxiety medication
173. Y N Has
anti-anxiety medication helped?
174.
_____ Tightness
across the shoulder 175.
_____ Stiff
in the morning 176.
_____ Joints
are stiff and swollen 177.
_____ Bursitis
or tendonitis 178. Y N Have
you ever had a herniated disc
179.
_____ Flexible
joints or “double jointed” 180.
_____ Joints
click or pop 181. Y N History
of stress fractures 182.
_____ Bone
loss (reduced density on bone scan, loss of height, etc. )
183. Y N Are
you shorter than you used to be? 184. Y N History
of kidney stones (or family tendency for kidney stones)
185. Y N Yellow
in the whites of the eyes 186.
_____ (Women)
Occasionally skip periods 187.
_____ (Women)
Excess facial hair 188.
_____ (Women)
Painful to have sexual intercourse 189.
_____ (Women)
Bleeding between periods 190.
_____ (Women
over 35) Irregular menstrual
cycle 191.
_____ (Women
over 35) Hot flashes 192.
_____ (Women
over 35) Decrease in libido as getting older 193.
_____ (Women)
Vaginal discharge 194.
_____ (Women)
Poor concentration associated with certain times of menstrual cycle
195.
_____ (Women)
Vaginal itching or dryness 196. Y N (Women)
Are you taking hormone replacement 197. Y N Women)
Have you had a partial hysterectomy 198. Y N (Women)
Have you had a total hysterectomy 199.
_____ (Women)
Cysts in breasts 200.
_____ (Women)
Ovarian cysts 201.
_____ (Women)
Scanty blood flow during period 202. Y N Take
synthroid or other thyroid hormone 203. Y N Are
you a vegan (no dairy, meat, or fish) 204.
_____ Nutrasweet
(aspartame) consumption (1=
1x/wk or less; 2= 2-3x/week;
3= 4-7x/week; 4= more than 1x daily) 205. _____ |
