MALE INTEGRATIVE HEALTH QUESTIONNAIRE

Step 1 of 17

General Information

Name

Age

General Information

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Address

City

State

Zip

Phone (Home)

(Cell)

(Work)

Genetic Background:

African

American

Hispanic

Mediterranean

Native American

Caucasian Northern European

Other

When, where and from whom did you last receive medical or health care?

Emergency Contact:

Relationship

Phone (Home)

(Cell)

(Work)

How did you hear about our practice?

Clinic website

IFM website

Social media

Referral from doctor

Referral from friend/family member

Other

Current Health Concerns

Please rank current and ongoing health concerns in order of priority

Describe Problem (Ex: Post Nasal Drip)

Severity

Mild (Yes/No)

Moderate (Yes/No)

Severe (Yes/No)

Prior Treatment/Approach

Excellent (Yes/No)

Good (Yes/No)

Fair (Yes/No)

Allergies

Name of Medication/Supplement/Food:

Reaction:

Lifestyle Review

Sleep

How many hours of sleep do you get each night on average?

Do you have problems falling asleep?

Yes

Staying asleep?

Yes

Do you have problems with insomnia?

Yes

Do you snore?

Yes

Do you feel rested upon awakening?

Yes

Do you use sleeping aids?

Yes

Explain:

Exercise

Current Exercise Program:

Activity

Type

# of Times Per Week

Time/Duration (Minutes)

Do you feel motivated to exercise?

Yes

A little

Are there any problems that limit exercise?

Yes

Explain:

Do you feel unusually fatigued or sore after exercise?

Yes

Explain:

Nutrition

Do you currently follow any of the following special diets or nutritional programs?

(Check all that apply)

Vegetarian

Vegan

Allergy

Elimination

Low Fat

Low Carb

High Protein

Blood Type

Low sodium

No Dairy

No Wheat

Gluten Free

Other

Mention

Do you have sensitivities to certain foods?

Yes

List food and symptoms:

Do you have an aversion to certain foods?

Yes

Explain:

Do you adversely react to:

(Check all that apply)

Monosodium glutamate (MSG)

Artificial sweeteners

Garlic/onion

Cheese

Citrus foods

Chocolate

Alcohol

Red wine

Sulfite-containing foods (wine, dried fruit, salad bars)

Preservatives

Food colorings

Other food substances:

Mention

Are there any foods that you crave or binge on?

Yes

What foods?

Do you eat 3 meals a day?

Yes

How many

Does skipping a meal greatly affect you?

Yes

How many meals do you eat out per week?

0-1

1-3

3-5

>5 meals per week

Check the factors that apply to your current lifestyle and eating habits:

Fast eater

Significant other or family members have special dietary needs

Eat too much needs Late-night eating

Love to eat

Dislike healthy foods

Eat because I have to

Time constraints

Have negative relationship to food Travel frequently

Struggle with eating issues

Eat more than 50% of meals away from home

Emotional eater (eat when sad, lonely, bored, etc.)

Healthy foods not readily available

Eat too much under stress

Poor snack choices

Eat too little under stress

Significant other or family members don't like Don't care to cook healthy foods

Confused about nutrition advice

Diet

Please record what you eat in a typical day:

Breakfast

Lunch

Dinner

Snacks

Fluids

How many servings do you eat in a typical week of these foods:

Fruits (not juice)

Vegetables (not including white potatoes)

Legumes (beans, peas, etc)

Red meat

Fish Dairy Alternatives

Nuts & Seeds

Fats & Oils

Cans of soda (regular or diet)

Sweets (candy, cookies, cake, ice cream, etc.)

Do you drink caffeinated beverages?

Yes

Coffee (cups per day)

2-4

Tea (cups per day)

2-4

Caffeinated sodas—regular or diet (cans per day)

2-4

Do you have adverse reactions to caffeine?

Yes

Explain

When you drink caffeine do you feel:

Irritable or wired

Aches or pains

Smoking

Do you smoke currently?

Yes

Packs per day:

Number of years

What type?

Cigarettes

Smokeless

Pipe

Cigar

E-Cig

Have you attempted to quit?

Yes

Using what methods:

If you smoked previously:

Packs per day:

Number of years

Are you regularly exposed to second-hand smoke?

Yes

Alcohol

How many alcoholic beverages do you drink in a week?

(1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)

1-3

4-6

7-10

>10

None

Previous alcohol intake?

Yes

None

Mild Moderate High

Mild

Moderate

High

Have you ever had a problem with alcohol?

Yes

When?

Explain the problem:

Have you ever thought about getting help to control or stop your drinking?

Yes

Other Substances

Are you currently using any recreational drugs?

Yes

Type:

Have you ever used IV or inhaled recreational drugs?

Yes

Stress

Do you feel you have an excessive amount of stress in your life?

Yes

Do you feel you can easily handle the stress in your life?

Yes

How much stress do each of the following cause on a daily basis

(Rate on scale of 1-10, 10 being highest)

Work

Family

Social

Finances

Health

Other

Do you use relaxation techniques?

Yes

How often?

Which techniques do you use?

(Check all that apply)

Meditation

Breathing

Tai Chi

Yoga

Prayer

Other

Have you ever sought counseling?

Yes

Are you currently in therapy?

Yes

Describe:

Have you ever been abused, a victim of crime, or experienced a significant trauma?

Yes

What are your hobbies or leisure activities?

Relationships

Marital status:

Single

Married

Divorced

Gay/Lesbian

Long-Term Partner

Widower

With whom do you live?

(Include children, parents, relatives, friends, pets)

Current occupation:

Previous occupations:

Do you have resources for emotional support?

Yes

Do you have resources for emotional support?

Spouse/Partner

Family

Friends

Religious/Spiritual

Pets

Other:

Mention

Do you have a religious or spiritual practice?

Yes

What kind?

How well have things been going for you?

(Mark on scale of 1-10, or N/A if not applicable)
(1-4=Poor, 5-9=Fine, 10=Very Well)

Overall

At school

In your job

In your social life

With close friends

With sex

With your attitude

With your boyfriend/girlfriend

With your children

With your parents

With your spouse

History

Patient's Birth/Childhood History:

You were born:

Term

Premature

Don't know

Were there any pregnancy or birth complications?

Yes

explain:

You were:

Breast-fed

Bottle-fed

Don't know

How long?

Type of formula:

Age of introduction of:

Solid food:

Wheat

Dairy

As a child, were there any foods that were avoided because they gave you symptoms? If yes, what foods and what symptoms?

Yes

What foods and what symptoms?

(Example: milk-gas and diarrhea)

Did you eat a lot of sugar or candy as a child?

Yes

Dental History:

Check if you have any of the following, and provide number if applicable:

Silver mercury fillings

Gold fillings

Root canals

Implants Caps/Crowns

Tooth pain

Bleeding gums

Gingivitis

Problems with chewing

Other dental concerns (explain)

Explain

Have you had any mercury fillings removed?

Yes

When?

How many fillings did you have as a kid?

Do you brush regularly?

Yes

Do you floss regularly?

Yes

Environmental/Detoxification History

Do any of these significantly affect you?

Cigarette smoke

Perfume/colognes

Auto exhaust fumes

Other

In your work or home environment are you regularly exposed to:

(Check all that apply)

Mold

Water leaks

Renovations

Chemicals

Electromagnetic radiation

Damp environments

Carpets or rugs

Old paint

Stagnant or stuffy air

Smokers

Pesticides

Herbicides

Harsh chemicals (solvents, glues, gas, acids, etc)

Cleaning chemicals

Heavy metals (lead, mercury, etc.)

Paints

Airplane travel

Other

Mention

Have you had a significant exposure to any harmful chemicals?

Yes

Chemical name

Length of exposure

Date:

MM slash DD slash YYYY

Do you have any pets or farm animals?

Yes

Do they live:

Inside

Outside

Both inside and outside

Men's History:

Men's History

Testicular mass

Testicular pain

Prostate enlargement

Prostate infection

Change in sex drive

Impotence

Premature ejaculation

Difficulty obtaining an erection

Difficulty maintaining an erection Loss of control of urine

Urinary urgency/hesitancy/change in stream

Vasectomy

Nocturia (urination at night)

Sexually transmitted diseases

# of times per night

Describe about STD

Men's History (cont.)

Screening/Procedures: (If applicable, provide date)

Last PSA test:

PSA Level:

0-2

2-4

4-10

>10

Other tests/procedures (list type and dates)

Family History:

Age (if still alive)

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Age at death (if deceased)

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Cancer

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Heart disease

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Hypertension

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Obesity

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Diabetes

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Stroke

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Autoimmune disease

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Arthritis

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Kidney disease

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Thyroid problems

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Seizures/epilepsy

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Psychiatric disorders

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Anxiety

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Depression

Mother

Father

Brother(s)

Sister(s)

Child

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other

Medical History:

Illnesses/Conditions Check YES = a condition you currently have, Check PAST = a condition you've had in the past.

Gastrointestinal

Irritable bowel syndrome

Yes

Past

GERD (reflux)

Yes

Past

Crohn's disease/ulcerative colitis

Yes

Past

Peptic ulcer disease

Yes

Past

Celiac disease

Yes

Past

Other:

Respiratory

Bronchitis

Yes

Past

Asthma

Yes

Past

Emphysema

Yes

Past

Sinusitis

Yes

Past

Sleep apnea

Yes

Past

Other:

Urinary/Genital

Kidney stones

Yes

Past

Gout

Yes

Past

Interstitial cystitis

Yes

Past

Frequent yeast infections

Yes

Past

Frequent urinary tract infections

Yes

Past

Sexual dysfunction

Yes

Past

Sexually transmitted diseases

Yes

Past

Other:

Endocrine/Metabolic

Diabetes

Yes

Past

Hypothyroidism (low thyroid)

Yes

Past

Hyperthyroidism (overactive thyroid)

Yes

Past

Polycystic

Yes

Past

Ovarian

Yes

Past

Syndrome

Yes

Past

Infertility

Yes

Past

Metabolic syndrome/insulin resistance

Yes

Past

Eating disorder

Yes

Past

Hypoglycemia

Yes

Past

Other:

Musculoskeletal

Fibromyalgia

Yes

Past

Osteoarthritis

Yes

Past

Chronic pain

Yes

Past

Other:

Skin

Eczema

Yes

Past

Psoriasis

Yes

Past

Acne

Yes

Past

Skin cancer

Yes

Past

Other:

Cardiovascular

Angina

Yes

Past

Heart attack

Yes

Past

Heart failure

Yes

Past

Hypertension (high blood pressure)

Yes

Past

Stroke

Yes

Past

High blood fats (cholesterol, triglycerides)

Yes

Past

Rheumatic fever

Yes

Past

Arrhythmia (irregular heart rate)

Yes

Past

Murmur

Yes

Past

Mitral valve prolapse

Yes

Past

Other:

Neurologic/Emotional

Epilepsy/Seizures

Yes

Past

ADD/ADHD

Yes

Past

Headaches

Yes

Past

Migraines

Yes

Past

Depression

Yes

Past

Anxiety

Yes

Past

Autism

Yes

Past

Multiple sclerosis

Yes

Past

Parkinson's disease

Yes

Past

Dementia

Yes

Past

Other:

Cancer

Lung

Yes

Past

Breast

Yes

Past

Colon

Yes

Past

Ovarian

Yes

Past

Skin

Yes

Past

Other:

Medical History (cont)

Diagnostic Studies

Date

Comments

Bone density

Date

MM slash DD slash YYYY

Comments

CT scan

Date

MM slash DD slash YYYY

Comments

Colonoscopy

Date

MM slash DD slash YYYY

Comments

Cardiac stress test

Date

MM slash DD slash YYYY

Comments

EKG

Date

MM slash DD slash YYYY

Comments

MRI

Date

MM slash DD slash YYYY

Comments

Upper endoscopy

Date

MM slash DD slash YYYY

Comments

Upper GI series

Date

MM slash DD slash YYYY

Comments

Chest

Date

MM slash DD slash YYYY

Comments

X-ray

Date

MM slash DD slash YYYY

Comments

Other

Date

MM slash DD slash YYYY

Comments

Surgeries

Appendectomy

Date

MM slash DD slash YYYY

Comments

Dental

Date

MM slash DD slash YYYY

Comments

Gallbladder

Date

MM slash DD slash YYYY

Comments

Hernia

Date

MM slash DD slash YYYY

Comments

Hysterectomy

Date

MM slash DD slash YYYY

Comments

Tonsillectomy

Date

MM slash DD slash YYYY

Comments

Joint replacement

Date

MM slash DD slash YYYY

Comments

Heart surgery

Date

MM slash DD slash YYYY

Comments

Other:

Date

MM slash DD slash YYYY

Comments

Hospitalizations

Date

Reason

Hospitalizations

Date

MM slash DD slash YYYY

Reason

Hospitalizations

Date

MM slash DD slash YYYY

Reason

Hospitalizations

Date

MM slash DD slash YYYY

Reason

Hospitalizations

Date

MM slash DD slash YYYY

Reason

Hospitalizations

Date

MM slash DD slash YYYY

Reason

Symptom Review

Please check if these symptoms occur presently or have occurred in the last 6 months

General

Cold hands and feet

Mild

Moderate

Severe

Cold intolerance

Mild

Moderate

Severe

Daytime sleepiness

Mild

Moderate

Severe

Difficulty falling asleep

Mild

Moderate

Severe

Early waking

Mild

Moderate

Severe

Fatigue

Mild

Moderate

Severe

Fever

Mild

Moderate

Severe

Flushing

Mild

Moderate

Severe

Heat intolerance

Mild

Moderate

Severe

Night waking

Mild

Moderate

Severe

Nightmares

Mild

Moderate

Severe

Can't remember dreams

Mild

Moderate

Severe

Low body temperature

Mild

Moderate

Severe

Head, Eyes, and Ears

Conjunctivitis

Mild

Moderate

Severe

Distorted sense of smell

Mild

Moderate

Severe

Distorted taste

Mild

Moderate

Severe

Ear fullness

Mild

Moderate

Severe

Ear ringing/buzzing

Mild

Moderate

Severe

Eye crusting

Mild

Moderate

Severe

Eye pain

Mild

Moderate

Severe

Eyelid margin redness

Mild

Moderate

Severe

Headache

Mild

Moderate

Severe

Hearing loss

Mild

Moderate

Severe

Hearing problems

Mild

Moderate

Severe

Migraine

Mild

Moderate

Severe

Sensitivity to loud noises

Mild

Moderate

Severe

Vision problems

Mild

Moderate

Severe

Musculoskeletal

Back muscle spasm

Mild

Moderate

Severe

Calf cramps

Mild

Moderate

Severe

Chest tightness

Mild

Moderate

Severe

Foot cramps

Mild

Moderate

Severe

Joint deformity

Mild

Moderate

Severe

Joint pain

Mild

Moderate

Severe

Joint redness

Mild

Moderate

Severe

Joint stiffness

Mild

Moderate

Severe

Muscle pain

Mild

Moderate

Severe

Muscle stiffness

Mild

Moderate

Severe

Muscle spasms

Mild

Moderate

Severe

Muscle twitches:

Mild

Moderate

Severe

Around eyes

Mild

Moderate

Severe

Arms or legs

Mild

Moderate

Severe

Muscle weakness

Mild

Moderate

Severe

Musculoskeletal (cont.)

Neck muscle spasm

Mild

Moderate

Severe

Tendonitis

Mild

Moderate

Severe

Tension headache

Mild

Moderate

Severe

TMJ problems

Mild

Moderate

Severe

Mood/Nerves

Agoraphobia

Mild

Moderate

Severe

Anxiety

Mild

Moderate

Severe

Auditory hallucinations

Mild

Moderate

Severe

Blackouts

Mild

Moderate

Severe

Depression

Mild

Moderate

Severe

Depression

Mild

Moderate

Severe

Difficulty:

Concentrating

Mild

Moderate

Severe

With balance

Mild

Moderate

Severe

With thinking

Mild

Moderate

Severe

With judgment

Mild

Moderate

Severe

With speech

Mild

Moderate

Severe

With memory

Mild

Moderate

Severe

Dizziness (spinning)

Mild

Moderate

Severe

Fainting

Mild

Moderate

Severe

Fearfulness

Mild

Moderate

Severe

Irritability

Mild

Moderate

Severe

Light-headedness

Mild

Moderate

Severe

Numbness

Mild

Moderate

Severe

Other phobias

Mild

Moderate

Severe

Panic attacks

Mild

Moderate

Severe

Paranoia

Mild

Moderate

Severe

Suicidal thoughts

Mild

Moderate

Severe

Seizures

Mild

Moderate

Severe

Tingling

Mild

Moderate

Severe

Tremor/trembling

Mild

Moderate

Severe

Visual hallucinations

Mild

Moderate

Severe

Symptom Review (cont.)

Please check if these symptoms occur presently or have occurred in the last 6 months

Urinary:

Bed wetting

Mild

Moderate

Severe

Hesitancy

Mild

Moderate

Severe

Infection

Mild

Moderate

Severe

Kidney disease

Mild

Moderate

Severe

Kidney stone

Mild

Moderate

Severe

Leaking/incontinence

Mild

Moderate

Severe

Pain/burning

Mild

Moderate

Severe

Urgency

Mild

Moderate

Severe

Digestion:

Anal spasms

Mild

Moderate

Severe

Bad teeth

Mild

Moderate

Severe

Bleeding gums

Mild

Moderate

Severe

Bloating of:

Mild

Moderate

Severe

Lower abdomen

Mild

Moderate

Severe

Whole abdomen

Mild

Moderate

Severe

Bloating after meals

Mild

Moderate

Severe

Blood in stools

Mild

Moderate

Severe

Burping

Mild

Moderate

Severe

Canker sores

Mild

Moderate

Severe

Cold sores

Mild

Moderate

Severe

Constipation

Mild

Moderate

Severe

Cracking at corner of lips

Mild

Moderate

Severe

Dentures w/poor chewing

Mild

Moderate

Severe

Diarrhea

Mild

Moderate

Severe

Difficulty swallowing

Mild

Moderate

Severe

Dry mouth

Mild

Moderate

Severe

Farting

Mild

Moderate

Severe

Fissures

Mild

Moderate

Severe

Foods "repeat" (reflux)

Mild

Moderate

Severe

Heartburn

Mild

Moderate

Severe

Hemorrhoids Intolerance to:

Mild

Moderate

Severe

Lactose

Mild

Moderate

Severe

All dairy products

Mild

Moderate

Severe

Gluten (wheat)

Mild

Moderate

Severe

Corn

Mild

Moderate

Severe

Eggs

Mild

Moderate

Severe

Fatty foods

Mild

Moderate

Severe

Yeast

Mild

Moderate

Severe

Liver disease/jaundice (yellow eyes or skin)

Mild

Moderate

Severe

Lower abdominal pain

Mild

Moderate

Severe

Mucus in stools

Mild

Moderate

Severe

Digestion (cont.):

Nausea

Mild

Moderate

Severe

Bulimia

Mild

Moderate

Severe

Periodontal disease

Mild

Moderate

Severe

Sore tongue

Mild

Moderate

Severe

Strong stool odor

Mild

Moderate

Severe

Undigested food in stools

Mild

Moderate

Severe

Upper abdominal pain

Mild

Moderate

Severe

Vomiting

Mild

Moderate

Severe

Eating:

Binge eating

Mild

Moderate

Severe

Can't gain weight

Mild

Moderate

Severe

Can't lose weight

Mild

Moderate

Severe

Carbohydrate craving

Mild

Moderate

Severe

Carbohydrate intolerance

Mild

Moderate

Severe

Poor appetite

Mild

Moderate

Severe

Salt cravings

Mild

Moderate

Severe

Frequent dieting

Mild

Moderate

Severe

Sweet cravings

Mild

Moderate

Severe

Caffeine dependency

Mild

Moderate

Severe

Breathing:

Bad breath

Mild

Moderate

Severe

Bad odor in nose

Mild

Moderate

Severe

Cough - dry

Mild

Moderate

Severe

Cough - productive

Mild

Moderate

Severe

Hayfever:

Mild

Moderate

Severe

Spring Summer

Mild

Moderate

Severe

Fall

Mild

Moderate

Severe

Change of season

Mild

Moderate

Severe

Hoarseness

Mild

Moderate

Severe

Nasal stuffiness

Mild

Moderate

Severe

Nose bleeds

Mild

Moderate

Severe

Post nasal drip

Mild

Moderate

Severe

Sinus fullness

Mild

Moderate

Severe

Sinus infection

Mild

Moderate

Severe

Snoring

Mild

Moderate

Severe

Sore throat

Mild

Moderate

Severe

Wheezing

Mild

Moderate

Severe

Winter stuffiness

Mild

Moderate

Severe

Symptom Review (cont.)

Please check if these symptoms occur presently or have occurred in the last 6 months

Nails:

Bitten

Mild

Moderate

Severe

Brittle

Mild

Moderate

Severe

Curve up

Mild

Moderate

Severe

Frayed

Mild

Moderate

Severe

Fungus - fingers

Mild

Moderate

Severe

Fungus - toes

Mild

Moderate

Severe

Pitting

Mild

Moderate

Severe

Ragged cuticles

Mild

Moderate

Severe

Ridges

Mild

Moderate

Severe

Soft

Mild

Moderate

Severe

Thickening of: Finger nails

Mild

Moderate

Severe

Thickening of: Toenails

Mild

Moderate

Severe

White spots/lines

Mild

Moderate

Severe

Lymph Nodes:

Enlarged/neck

Mild

Moderate

Severe

Tender/neck

Mild

Moderate

Severe

Enlarged/neck

Mild

Moderate

Severe

Other enlarged/tender

Mild

Moderate

Severe

lymph nodes

Mild

Moderate

Severe

Skin, Dryness of:

Eyes

Mild

Moderate

Severe

Feet: Any cracking?

Mild

Moderate

Severe

Feet: Any peeling?

Mild

Moderate

Severe

Hair: And unmanageable?

Mild

Moderate

Severe

Hands: Any cracking?

Mild

Moderate

Severe

Hands: Any peeling?

Mild

Moderate

Severe

Mouth/throat

Mild

Moderate

Severe

Scalp: Any dandruff?

Mild

Moderate

Severe

Skin in general

Mild

Moderate

Severe

Skin Problems (cont.):

Ears get red

Mild

Moderate

Severe

Easy bruising

Mild

Moderate

Severe

Eczema

Mild

Moderate

Severe

Herpes genital

Mild

Moderate

Severe

Hives

Mild

Moderate

Severe

Jock itch

Mild

Moderate

Severe

Lackluster skin

Mild

Moderate

Severe

Moles w color/size change

Mild

Moderate

Severe

Oily skin

Mild

Moderate

Severe

Pale skin

Mild

Moderate

Severe

Patchy dullness

Mild

Moderate

Severe

Psoriasis

Mild

Moderate

Severe

Rash

Mild

Moderate

Severe

Red face

Mild

Moderate

Severe

Sensitive to bites

Mild

Moderate

Severe

Sensitive to poison ivy/oak

Mild

Moderate

Severe

Shingles

Mild

Moderate

Severe

Skin cancer

Mild

Moderate

Severe

Skin darkening

Mild

Moderate

Severe

Strong body odor

Mild

Moderate

Severe

Thick calluses

Mild

Moderate

Severe

Vitiligo

Mild

Moderate

Severe

Itching Skin:

Anus

Mild

Moderate

Severe

Arms

Mild

Moderate

Severe

Ear canals

Mild

Moderate

Severe

Eyes

Mild

Moderate

Severe

Feet

Mild

Moderate

Severe

Hands

Mild

Moderate

Severe

Legs

Mild

Moderate

Severe

Nipples

Mild

Moderate

Severe

Nose

Mild

Moderate

Severe

Genitals

Mild

Moderate

Severe

Roof of mouth

Mild

Moderate

Severe

Scalp

Mild

Moderate

Severe

Skin in general

Mild

Moderate

Severe

Throat

Mild

Moderate

Severe

Male Reproductive:

Discharge from penis

Mild

Moderate

Severe

Ejaculation problem

Mild

Moderate

Severe

Genital pain

Mild

Moderate

Severe

Impotence

Mild

Moderate

Severe

Infection

Mild

Moderate

Severe

Lumps in testicles

Mild

Moderate

Severe

Poor libido (low sex drive)

Mild

Moderate

Severe

Current Medications

Current medications (include prescription and over-the-counter)

Current Medications

Medication

Dosage

Start Date

Reason for Use

Current Supplements

Supplements

Dosage

Start Date

Reason for Use

Have medications or supplements ever caused unusual side effects or problems?

Yes

Describe:

Have you used any of these regularly or for a long time:

NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin?

Yes

Tylenol (acetaminophen)?

Yes

Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?

Yes

How many times have you taken antibiotics?

Infancy/Childhood

Reson for Use

Teen

Reson for Use

Adulthood

Reson for Use

Have you ever taken long-term antibiotics?

Yes

Describe:

How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)

Infancy/Childhood

Reson for Use

Teen

Reson for Use

Adulthood

Reson for Use

Readiness Assessment and Health Goals

Readiness Assessment

Rate on a scale of 5 (very willing) to 1 (not willing):
In order to improve your health, how willing are you to:

Significantly modify your diet

Take several nutritional supplements each day

Keep a record of everything you eat each day

Modify your lifestyle (e.g., work demands, sleep habits)

Practice a relaxation technique

Engage in regular exercise

Rate on a scale of 5 (very confident) to 1 (not confident at all):

How confident are you of your ability to organize and follow through on the above health-related activities?

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?

Rate on a scale of 5 (very supportive) to 1 (very unsupportive):

At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):

How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program?

Comments

Health Goals

What do you hope to achieve in your visit with us?

When was the last time you felt well?

Did something trigger your change in health?

What makes you feel better?

What makes you feel worse?

How does your condition affect you?

What do you think is happening and why?

What do you feel needs to happen for you to get better?

General Information

Lifestyle Review

Sleep

Nutrition

Diet

How many servings do you eat in a typical week of these foods:

Smoking

If you smoked previously:

Alcohol

Other Substances

Stress

How much stress do each of the following cause on a daily basis

Relationships

How well have things been going for you?

History

Patient's Birth/Childhood History:

Age of introduction of:

Environmental/Detoxification History

Men's History:

Men's History (cont.)

Medical History:

Gastrointestinal

Respiratory

Urinary/Genital

Endocrine/Metabolic

Musculoskeletal

Skin

Cardiovascular

Neurologic/Emotional

Cancer

Medical History (cont)

Symptom Review

Symptom Review (cont.)

Symptom Review (cont.)

Current Medications

Current Supplements

Have you used any of these regularly or for a long time:

Readiness Assessment and Health Goals

Readiness Assessment

Health Goals

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