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