The Heavens Declare His Handiwork

Previous Page               Next Page

 

Thomas Lee Abshier, ND
—-
Naturopathic Physician

Christian Counselor

Political Philosopher & Author

 

—
Marriage & Personal Counseling

Medical Consultations

—

1414 NE 109th Ave.

Portland, Oregon

(503) 255-9500
drthomas@naturedox.com
 

Patient Intake Form: Part #3

 

 

Nutritional Assessment Questionnaire:

 

 

Name _________________________________________________
Sex ____ Age ______ Date _____/____/_____

Medications currently using ___________________________________________________________________ ____________

Supplements currently taking ___________________________________________________________________ ____________

Five Most Significant Health Problems ___________________________________________________________________ ____________

___________________________________________________________________ ____________

Circle any of the following item you consume:      

  Alcohol Dairy products Margarine  

  Candy or other sweets Deep fried foods Non-herbal tea  

  Chewing tobacco Distilled water Refined (white) flour products  

  Cigarettes Fast food Refined sugar  

  Cigars Fluoridated/chlorinated water Soft drinks  

  Coffee Luncheon meats   

 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. _____ Sweat has strong odor

206. Y N Do you have tinnitus (ringing in your ears)

207. _____ Do you consume margarine? (1= 1x/wk or less; 2= 2-3x/week; 3= 4-7x/week; 4= more than 1x daily)

208. _____ Small bumps on the back of the arm

209. _____ Trouble seeing at night

210. Y N Lateral 1/3 of eyebrows doesn’t grow hair

211. _____ Eyes itch during hay fever season

212. _____ Rapid heart beat

213. _____ Anxious, nervous or jittery

214. _____ Bad breath

    

Intake Questionnaires | Home Page | Homeopathic Intake | General Intake 1 | Review of Systems | Physical Exam | Laboratory Tests | Informed Consent




  

   

 

Naturopathic Medicine - the Holistic Healing Paradigm

Including: Orthomolecular, Functional, Herbal & Homeopathic Medicine

Goal: Restoring the Body’s God Given Pattern of Health
Method: Removing the Resistance to Cure, and
Proper Nutrition, Lifestyle, Relationship, & Body Mechanics

Diagnosis: Lab & Clinical Indications of Errors of Metabolism, Lifestyle, and Genetics