Health Questionnaire

  

Symptoms/Ailments you are most concerned with:

 

Symptoms of secondary concern:

 

What treatments have you had so far, of any type?

 

Did any of them help at all, and if so how much and in what way?

Is there anything you do at home that reduces your symptoms? (For example, “better with rest” ,  “better with walking, ” ” better with heat.”)

Is there anything you do that makes it worse?  (For example, “worse with running” “worse with alcohol.”)

 

Please give a brief history of your complaints:

When did they begin?

What were you doing at the time?

Were there any directly noticeable causes, e.g. sprained ankle dancing?

What was going on in your life at the time in terms of stressors and emotional conditions, e.g. “right after retiring from my job i developed hives“ “my wife and I were getting divorced and i started getting heartburn“

 

 

Sleep:

Do you have any trouble falling or staying asleep?

If so, give details.

Do you feel refreshed in the morning?

Appetite:

Strong, Weak, Excessive? Can you eat anything or are you a fussy eater?

Digestion: (Upper GI)

Do you feel good after eating? 

Any indigestion after eating, bloating, belching, heartburn, pain, fatigue after eating?

Any diagnoses such as GERD, Gastritis, Ulcer?

Elimination: Lower GI

Bowel movements daily? How many times? If not, how often.

Are they well formed, or more like “rocks” or “snakes”

Any constipation or diarrhea with stress?  Any intestinal bloating or pain. 

Any Lower GI diagnoses like IBS, UC, Diverticulitis?

Uro-genital:

Have you had any urinary tract, yeast, or kidney infections? If so, how many?

Men: Any issues with prostate gland, erectile dysfunction or other uro-gential problems.

Any interstitial cystitis or neurgenic bladder?

Any STDs?

Menstrual.

Ago at time of first period?

Does your period come at regular intervals?

Is it usually about the same number of days of bleeding?

Is the bleeding light, medium, or heavy?

How many days are heavy?

Do you suffer from any symptoms WITH the bleeding, such as cramps, clots, leg pain, constipation, headache.

Do you suffer from any pre-menstural symptoms, such as bloating, swollen tender breasts, food cravings, bowel changes, emotional changes such as irritability or crying from things you would not normally cry at? Please be specific.

Libido:

Would you describe it as high, average, or below average?

Men: any unusual levels of fatigue with sexual activity.

Energy: 

Describe your typical energy level –high, low, medium

Any abnormal fatigue

Body Temp: 

Do you prefer to be cool or warm.

For example, do you like to sleep with a blanket even in warm weather? Are you bundled up when others are not? Do you wear shorts and T shirt when others are warmly dressed? Does hot sun make you feel uncomfortable or headachy?

Climate: 

What kind of climate do you prefer–warm, cool, hot, cold, damp, dry

For example, if warm, do you prefer dry heat or moist heat?

What kind of climate do you dislike? For exampl, “i hate the desert in summer and i hate wind”

Feelings:

Would you describe yourself as by nature fundamentally happy, sad, angry, worried, fearful, easygoing, pensive, dominating/controlling?

Do any of these occur more predominately or as a recurring theme?

How happy are you generally speaking with your life right now?

How happy with work, friendships, spousal relationship if applicable?

What do you do to relax?

Do you meditate or have any kind of spiritual practice?

What do you do for fun?

Stress: 

Rate your stress level on a scale of 1 to 10

What do you feel when stressed? Where in your body? For example, “upset stomach, nausea, keyed up, can’t relax, must stay busy, irritable, tense shoulders and face, worried”

Exercise: 

How often and what kind?

Substances/Self Medication:

Do you consume caffeine, tobacco, alcohol, marijuana, or any other non-prescription drugs? How much and how frequently?

Do you binge on sugar?

Medical drugs:

Please list any pharmaceutical drugs, nutritional supplements, or herbal medicines you currently take.

Diet:

What do you eat? Please give a thumbnail sketch of breakfast, lunch, dinner, snacks, beverages, and favored treats.

Are you happy with your diet at this point in time?

 

That’s It! Thank you!

 

 

 

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