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General Information

First Name *

Middle Name

Last Name *

Email Address

Date of Birth *

/ /

Age

Place of Birth

Where did you spend most of your life growing up?

Sex *

Occupation

Married or single?

Married
Single

Referred By

How did you hear about us?

Ethnicity

Please check all that apply:

African American
Asian
Caucasian
Hispanic
Mediterranean

Native American
Northern European
Pacific Islander
Other

Social History Questions

Stress level	Smoking History? If yes, how much?
Alcohol intake? If yes, average weekly intake?	Drug Use now or in past? Yes No

Eating Habits

Common Foods Eaten #1	Common Foods Eaten #2	Common Foods Eaten #3
Exercise routine?

Allergies/Intolerances

Do you have any Allergies? Yes No
Allergy #1	Allergy #2	Allergy #3

Wellness - When did you last feel optimally well? This time must precede any diagnosis of illness and/or any prescribed medications.

Last time optimally well?

Problems - Please rank current and ongoing problems by Priority and severity - while also filling in the other boxes as completely as possible:

Ongoing Problem (1)	Ongoing Severity (1)	Ongoing Treatment (1)	Ongoin Success (1)
Ongoing Problem (2)	Ongoing Severity (2)	Ongoing Treatment (2)	Ongoin Success (2)
Ongoing Problem (3)	Ongoing Severity (3)	Ongoing Treatment (3)	Ongoin Success (3)
Ongoing Problem (4)	Ongoing Severity (4)	Ongoing Treatment (4)	Ongoin Success (4)
Ongoing Problem (5)	Ongoing Severity (5)	Ongoing Treatment (5)	Ongoin Success (5)
Ongoing Problem (6)	Ongoing Severity (6)	Ongoing Treatment (6)	Ongoin Success (6)
Ongoing Problem (7)	Ongoing Severity (7)	Ongoing Treatment (7)	Ongoin Success (7)
Ongoing Problem (8)	Ongoing Severity (8)	Ongoing Treatment (8)	Ongoin Success (8)
Ongoing Problem (9)	Ongoing Severity (9)	Ongoing Treatment (9)	Ongoin Success (9)
Ongoing Problem (10)	Ongoing Severity (10)	Ongoing Treatment (10)	Ongoin Success (10)

Medical and Surgical History

ILLNESSES	WHEN	COMMENTS
Anemia	/ /
Arthritis	/ /
Asthma	/ /
Bronchitis	/ /
Cancer	/ /
Chronic Fatigue Syndrome	/ /
Crohn's Disease or Ulcerative Colitis	/ /
Diabetes	/ /
Emphysema	/ /
Epilepsy, Convulsions, or Seizures	/ /
Gallstones	/ /
Gout	/ /
Heart Attack/Angina	/ /
Heart Failure	/ /
Hepatitis	/ /
High Blood Fats	/ /
High Blood Pressure	/ /
Irritable Bowel	/ /
Kidney Stones	/ /
Mononucleosis	/ /
Pneumonia	/ /
Rheumatic Fever	/ /
Sinusitis	/ /
Sleep Apnea	/ /
Stroke	/ /
Thyroid Disease	/ /
Other (describe)	/ /

INJURIES (TYPE)	DATE	TREATMENT
	/ /
	/ /
	/ /

DIAGNOSTIC STUDIES	WHEN	COMMENTS
Barium Enema	/ /
Bone Scan	/ /
CAT of Abdomen	/ /
CAT Scan of Brain	/
CAT Scan of Spine	/ /
Chest X-ray	/ /
Colonoscopy	/ /
EKG	/ /
Liver Scan	/ /
Neck X-ray	/ /
NMR/MRI	/ /
Sigmoidoscopy	/ /
Upper GI Series	/ /
Other (describe)	/ /

OPERATIONS	WHEN	COMMENTS
Appendectomy	/ /
Dental Surgery	/ /
Gall Bladder	/ /
Hernia	/ /
Hysterectomy	/ /
Tonsillectomy	/ /
Other (describe)	/ /
Other (describe)	/ /

Hosptializations

WHERE HOSPITALIZED	WHEN	REASON
	/ /
	/ /
	/ /

Antibiotics

Infancy / Childhood

Teen

Adulthood

Medications & Prescription Drugs - What medications are you taking now? Include non-perscription drugs.

MEDICATION NAME	DATE STARTED	DOSAGE
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /

Vitamin / Mineral / Supplements - List all Vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or UI and the form (e.g. calcium carbonate vs. calcium lactate), when possible.

VITAMIN / MINERAL / SUPPLEMENTS	DATE STARTED	DOSAGE
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /
	/ /

Family History

PRINT NAMES BELOW

HEALTH

ILLNESSES

Name (Father)

Health

Age and Cause of Death

Name (Mother)

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Sibling#1) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Sibling#2) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Sibling#3) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Sibling#4) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease

Heart Trouble
High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Spouse) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Child#1) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Child#2) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Child#3) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

(Child#4) Name

Health

Age and Cause of Death

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

Paternal Relatives

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

Maternal Relative

Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

Paternal Grandparents

Paternal Grandparents Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

Maternal Grandparents

Maternal Grandparents Illness

Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Trouble

High Blood Pressure
Kidney or Bladder Disease
Nervous Breakdown
Rheumatism or Arthritis
Stomach or Duodenal Ulcer

Symptoms (General)

Fatigue	Mild	Medium	Severe
Difficulty Sleeping	Mild	Medium	Severe
Cold Intolerance	Mild	Medium	Severe
Cold Hands and Feet	Mild	Medium	Severe
Hot Intolerance	Mild	Medium	Severe

Symptoms (Head, Eyes,Ears)

Headaches	Mild	Medium	Severe
Migraines	Mild	Medium	Severe
Ear Problems	Mild	Medium	Severe
Eye Problems	Mild	Medium	Severe
Hearing Problems	Mild	Medium	Severe
Vision Problems	Mild	Medium	Severe
Sensitivity to Smells	Mild	Medium	Severe

Symptoms (Musculoskeletal)

Back Pain	Mild	Medium	Severe
Joint Pain	Mild	Medium	Severe
Muscle Pain	Mild	Medium	Severe
Muscle Cramps	Mild	Medium	Severe
Limited Range of Motion	Mild	Medium	Severe
TMJ Problems	Mild	Medium	Severe

Symptoms (Mood/Nerves)

Anxiety	Mild	Medium	Severe
Panic Attacks	Mild	Medium	Severe
Depression	Mild	Medium	Severe
Suicidal Thoughts	Mild	Medium	Severe
Difficulty Concentrating	Mild	Medium	Severe
Difficulty with Memory	Mild	Medium	Severe
Irritability	Mild	Medium	Severe
Dizziness	Mild	Medium	Severe
Light-Headed	Mild	Medium	Severe
Numbness	Mild	Medium	Severe
Seizures	Mild	Medium	Severe
Tremors	Mild	Medium	Severe
Hallucinations	Mild	Medium	Severe

Symptoms (Eating)

Anorexia	Mild	Medium	Severe
Bulimia	Mild	Medium	Severe
Can't Lose Weight	Mild	Medium	Severe
Weight Distribution	Mild	Medium	Severe
Can't Gain Weight	Mild	Medium	Severe
Carb/Sugar Cravings	Mild	Medium	Severe
Salt Cravings	Mild	Medium	Severe
Chocolate Cravings	Mild	Medium	Severe
Loss of Appetite	Mild	Medium	Severe

Symptoms (Digestion)

Canker Sores	Mild	Medium	Severe
Bad Teeth	Mild	Medium	Severe
Cracking Corners of Mouth	Mild	Medium	Severe
Bleeding Gums	Mild	Medium	Severe
Bloating/Gas	Mild	Medium	Severe
Blood in Stools	Mild	Medium	Severe
Black Stools	Mild	Medium	Severe
Constipation	Mild	Medium	Severe
Diarrhea	Mild	Medium	Severe
Undigested Food in Stool	Mild	Medium	Severe
Difficulty Swallowing	Mild	Medium	Severe
Reflux/Heartburn	Mild	Medium	Severe
Hemorrhoids	Mild	Medium	Severe
Intolerance to Dairy	Mild	Medium	Severe
Intolerance to Gluten/Wheat	Mild	Medium	Severe
Intolerance to Corn	Mild	Medium	Severe
Intolerance to Eggs	Mild	Medium	Severe
Intolerance to Fatty Foods	Mild	Medium	Severe
Jaundice	Mild	Medium	Severe
Liver Problems	Mild	Medium	Severe
Abdominal Pain	Mild	Medium	Severe
Nausea/Vomiting	Mild	Medium	Severe

Symptoms (Skin & Nails)

Acne	Mild	Medium	Severe
Dry Skin	Mild	Medium	Severe
Cellulitis/Folliculitis	Mild	Medium	Severe
Rash	Mild	Medium	Severe
Skin Sensitivities	Mild	Medium	Severe
Eczema	Mild	Medium	Severe
Psoriasis	Mild	Medium	Severe
Herpes	Mild	Medium	Severe
Easy Bruising/Bleeding	Mild	Medium	Severe
Skin Cancer	Mild	Medium	Severe
Vitiligo	Mild	Medium	Severe
Itchy Skin	Mild	Medium	Severe
Brittle Nails	Mild	Medium	Severe
Nail Changes	Mild	Medium	Severe

Symptoms (Respiratory)

Cough	Mild	Medium	Severe
Shortness of Breath	Mild	Medium	Severe
WheezingChoice 1	Mild	Medium	Severe
Asthma	Mild	Medium	Severe
Sinus Problems	Mild	Medium	Severe
Post Nasal Drip	Mild	Medium	Severe
Snoring	Mild	Medium	Severe

Symptoms (Cardiovascular)

Chest Pain/Angina	Mild	Medium	Severe
Heart Attack	Mild	Medium	Severe
Heart Murmur	Mild	Medium	Severe
High Blood Pressure	Mild	Medium	Severe
Irregular Pulse	Mild	Medium	Severe
Mitral Valve Prolapse	Mild	Medium	Severe
Palpitations	Mild	Medium	Severe
Swollen Ankles/Feet	Mild	Medium	Severe

Symptoms (Urinary)

Infection	Mild	Medium	Severe
Kidney Disease/Stones	Mild	Medium	Severe
Incontinence	Mild	Medium	Severe
Pain/Burning	Mild	Medium	Severe
Urgency	Mild	Medium	Severe

Symptoms (Reproductive Male)

Prostate Problems	Mild	Medium	Severe
Penile Discharge	Mild	Medium	Severe
Infections	Mild	Medium	Severe
Impotence	Mild	Medium	Severe
Ejaculation Problems	Mild	Medium	Severe
Low Sex Drive/Libido	Mild	Medium	Severe

Symptoms (Reproductive Female)

Breast Problems	Mild	Medium	Severe
Ovarian Problems	Mild	Medium	Severe
Low Sex Drive/Libido	Mild	Medium	Severe
Endometriosis	Mild	Medium	Severe
Fibroids	Mild	Medium	Severe
Vaginal Problems	Mild	Medium	Severe
Infertility	Mild	Medium	Severe
Night Sweats	Mild	Medium	Severe
Hot Flashes	Mild	Medium	Severe

Symptoms (Premenstrual Symptoms)

Breast Tenderness	Mild	Medium	Severe
Bloating	Mild	Medium	Severe
Food Cravings	Mild	Medium	Severe
Constipation	Mild	Medium	Severe
Diarrhea	Mild	Medium	Severe
Sleep Problems	Mild	Medium	Severe
Fatigue	Mild	Medium	Severe
Irritability	Mild	Medium	Severe

Symptoms (Menstrual Problems)

Cramps	Mild	Medium	Severe
Heavy Flow	Mild	Medium	Severe
Irregular Mensus	Mild	Medium	Severe
No Periods	Mild	Medium	Severe
Spotting Between	Mild	Medium	Severe

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African American	Asian	Caucasian	Hispanic	Mediterranean
Native American	Northern European	Pacific Islander	Other