* Required fields
Name *
E-mail Address *
Ht. *
Wt. *
Age *
Address *
City *
State *
Zip *
D.O.B. *
SS# - optional
Home Phone *
work Phone
Fax
Employment
Family Physician
Cardiologist
THYROID/PARATHYROID (Glandular System)
Are you overweight? *
Do you get cold Hands and feet
Do you have hair loss or are you bald or going bald?
Is it easy to put on weight and hard to loose it?
Are your fingernails ridged, brittle or weak?
Do you have varicose or spider veins?
Do you, or have you had hemorrhoids?
Do you get cramping in your muscles?
Is your bladder strong or weak?
Do you have an irregular heartbeat?
Do you have Mitral Valve Prolapse (Heart Murmur)
Do you get headaches or migraines?
Have you now have, or ever had a hernia?
Have you ever had aneurysm?
Do you have osteoporosis?
Do you have scoliosis?
Do you get irritable easily?
Do you have low energy levels?
Do you suffer from symptoms of depression?
Did you score low on your bone density test?
Do your tests come back showing Low Calcium levels?
Do you have, or have you ever had, a goiter
Do you have spine deterioration or herniated discs?
Have you been diagnosed with Hashimoto or Reidel disease? (Or any family member)
Do you sweat profusely or hardly at all?
ADRENAL GLANDS (Glandular System) MEDULLA (ADRENAL)
Do you have M.S., Parkinson's or Palsy?
Do you have anxiety attacks, or feel overly anxious?
Do you feel excessive shyness, or inferior to others?
Do you have low blood pressure (below 118 systolic)?
Do you have tremors, nervous legs, etc.?
Do you have tinnitus (ringing in the ear)?
Do you have S.O.B. (shortness of breath) or is it hard to take a deep breath?
Do you have heart arrhythmias?
Do you have a hard time sleeping?
Do you have Chronic Fatigue Syndrome?
Do you get tired easily?
Have you ever been diagnosed/Addison's Disease or with Congenital Adrenal Hyperplasia?
CORTEX (Adrenal)
Do you have elevated blood cholesterol levels?
Do you have lower back weakness?
Do you have, or have you had, sciatica?
Do you have arthritis or bursitis?
Do you have any itis's (inflammatory conditions)?
If yes, Explain please:
FEMALE ONLY
Are your menstruation's irregular?
Do you get excessive bleeding during menstruation?
Do you have or have you had ovarian cysts?
Do you have or did you have fibroid's?
Do you have or did you have endometriosis or A-typical cells?
Are you fibrocystic?
Do you have fibromyalgia or scleroderma?
Do you get sore breasts, especially during menstruation?
Do you have a low or excessive sex drive?
Have you had a Hysterectomy?
EXPLAIN When? Partial or Complete
Did they take any other organs out at the same time? (c.a. gallbladder)
Have you had a D & C?
Have you had a miscarriage?
Have you had difficulty in conceiving children?
Other, explain.
MALE ONLY
Do you have prostatitis (frequent urination esp at night)?
If yes, how often
Do you have prostate cancer?
PSA coun's please
Do you have testicular hypertrophy (enlargement)?
Do you have a low or excessive sex drive?
Do you have erection problems?
Do you have premature ejaculation?
PANCREAS
Do you get gas after you eat?
Do you feel your foods just sitting in your stomach
Do you have acid reflux?
Do you see any undigested food in your stools?
Do you have hypoglycemia (Low Blood Sugar)
Do you have Diabetes (High Blood Sugar)?
Type I or Type II
Are you thin and have a hard time putting on weight?
Do you have gastritis or enteritis?
Do your foods pass right through you (diarrhea)?
Do you have moles on your body?
GASTRO-INTESTINAL TRACT
Is your tongue coated (white, yellow, green or brown), especially in the morning?
Do you have a Hiatus Hernia?
Do you have Gastritis?
Do you have Enteritis?
Do you have Colitis?
Do you have Diverticulitis?
Do you get or have Diarrhea?
Do you get or have Constipation?
Do you have Bowel Movement?
How often explain!
Have you ever had stomach or intestinal ulcers?
Do you or have you ever had any type of gastro-intestinal cancer: stomach, colon, rectal, etc.
Explain:
Do you have Crohn's Disease?
Do you have "gas" problems?
Other GI problems?
Please explain:
LIVER / GALLBLADDER / BLOOD
Do you have a problem digesting fats?
Do fats or dairy foods cause bloating and/or pain in the stomach area?
Are your stools white or very light brown in color?
Do you get pain in the middle of your back (especially after eating)?
Do you get pain behind the right, lower rib area?
Do you have "liver" or brown spots on your skin? (not freckles)
Do you have any skin pigmentation changes?
Do you have skin problems?
If "yes" what type?
Are you anemic?
Do you have, or have you ever had, hepatitis?
If "yes" what type, "A" "B" or "C", explain
HEART AND CIRCULATION
Do you have any gray hair?
Do you have a hard time remembering things?
Do your legs get tired or cramp after you walk?
Do you bruise easily?
Do you get chest pains or angina?
Have you ever had a heart attack (Myocardial Infarction)?
Have you ever had open-hart surgery?
Do you have heart arrhythmia's?
If yes, what kind?
Do you have a Heart murmur or Mitral Valve Prolapse?
Do you ever feel pressure on your chest?
Do you get "prickly"pains anywhere, especially in the heart area?
Where?
Do you have, or have you ever had High Blood Pressure?
Your average Blood Pressure is
SKIN
Do you get or have skin rashes?
Do you get skin blemishes?
Do you have Eczema or Dermatitis?
Do you have Psoriasis?
Do you itch anywhere?
If "yes" where?
Is your skin dry?
Is your skin excessivley oily?
Do you get or have dandruff?
LYMPHATIC SYSTEM
Are you allergic to anything?
If yes, what?
Do you ever get cold or flu-like symptoms
Do you have sinus problems?
Do you have or get sore throats?
Do you have swollen lymph nodes
Do you have or had tumors?
If yes, what type?
Where?
Do you have a low platelet count (blood)?
Is your immune System low or sluggish?
Have you had appendicitis or an appendectomy?
When?
Do you get boils, pimples, and the like?
Do you have allergies?yes no
Have you ever had abscesses?
Have you ever had toxemia?
Do you have, or have you had , cellulitis?
Have you ever had gout?
Do you get blurred vision?
Do you have mucus in your eyes when you wake up in the morning?
Do you snore?
Do you have sleep apnea?
Have you had your tonsils out?
If yes, What age?
KIDNEY AND BLADDER
Have you ever had a urinary tract infection (UTI's)
Have you ever had "burning" upon urination?
Do you have problems holding your bladder (para-thyroid)?
Have you ever had kidney stones?
Do you have bags under your eyes (esp. in the morning)?
Is your urine flow restricted?
Do you get cramping or pain on either side of your mid-to-lower back?
Do you or did you ever have nephritis?
Do you or did you ever have cystitis?
LUNGS
Do you get or have (or have had) bronchitis?
Do you get or have (or have had) emphysema?
Do you get or have (or have had) asthma?
Do you get or have (or have had) C.O.P.D.?
Are you on inhalers or nebulizers?
If yes, how often
What type?
Do you know what your oxygen saturation is?
Do you get pain when you breathe?
Do you get pain when you take a deep breath?
Did you ever or do you have lung cancer?
Do you have a collapsed lung?
Are you a smoker?
How often?
Have you ever had pneumonia?
Have you ever worked around toxic chemicals, in coal mines or around asbestos?
Do you cough a lot?
Do you get any mucus when you cough?
What color is the mucus, explain.
OTHER (What are your main health complaints or concerns?) Please list and elaborate on any conditions or symptoms that this questionnaire has not covered or asked you.
PAST SURGERIES and Year. Please list any past surgeries you have had (e.g. tonsils removed, hysterectomies, open heart surgery, etc.)
CHEMICAL MEDICATIONS
What Medication?
Reasons:
NATURAL SUPPLEMENTS
Supplements:
Vitamins and Minerals:
ALLERGIES
Allergy: Please list anything that you are allergic to.
GENETIC HISTORY
Mom, please explain:
Dad, please explain.
(Maternal) Grandfather: pls. explain
(Maternal) Grandmother: pls. explain
(Fraternal) Grandfather: pls. explain
(Fraternal) Grandmother: pls. explain
Sister: pls. explain
Sister: pls. explain
Brother: pls. explain
Brother: pls. explain
Privacy Policy *
