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