Patient FormsStep 1 of 250%Name(Required)AgeDate of Birth MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone # (Home)(Required)Phone # (Work)Phone # (Cell)(Required)Email Address(Required) EmployerEmergency ContentRelationshipPhone #Please circle or list how you heard about our office Referral Google Facebook Sign Newspaper OtherHeightWeightDesired Weight GoalWhy are you seeking weight loss at this time?What was your lowest adult weight and when?What was your highest adult weight and when?What is your usual body weight range?Reason/s for your weight gainHow many times a day do you eat?1234567Indicate which meals/snacks you typically eat: Breakfast am snack lunch pm snack dinner evening snackPlease list any past or present diagnosed medical conditions.(Required)Please type ‘none’ if not applicable.Alcohol (please specify how many oz per week)Coffee/tea (please specify how many cups per day)Smoking ( ____cig/day ___#years ___year quit____ )FEMALES – Please completeMenopause Yes No# Yrs.Menstrual flow Regular Irregular Pain/CrampsDays of flowLength of cycleDate of 1st day of last period MM slash DD slash YYYY Pain/bleeding during or after sex Yes NoPregnancies (number of)# Live births (number of)# Abortions (number of)# Miscarriages (number of)Birth Control methodBirth control pill nameBirth control pill nameDate of last PAP test MM slash DD slash YYYY PAP test result Normal AbnormalDate of last Mammogram MM slash DD slash YYYY Mammogram result Normal AbnormalNotesPART I Please list your 5 major health concerns in order of importance: Please check on the scale of 1-10, how committed are you to correcting each concern with “10” being the most committed.1st major health concerns1st concern note123456789102nd major health concerns2nd concern note123456789103th major health concerns3th concern note123456789104th major health concerns4th concern note123456789105th major health concerns5th concern note12345678910PART II Please check the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.Category IFeeling that bowels do not empty completely 0 1 2 3Lower abdominal pain relieved by passing stool or gas 0 1 2 3Alternating constipation and diarrhea 0 1 2 3Diarrhea 0 1 2 3Constipation 0 1 2 3Coated tongue or “fuzzy” debris on tongue 0 1 2 3Hard, dry, or small stool 0 1 2 3Pass large amount of foul-smelling gas 0 1 2 3More than 3 bowel movements daily 0 1 2 3Use laxatives frequently 0 1 2 3Category IIIncreasing frequency of food reactions 0 1 2 3Unpredictable food reactions 0 1 2 3Aches, pains, and swelling throughout the body 0 1 2 3Unpredictable abdominal swelling 0 1 2 3Frequent bloating and distention after eating 0 1 2 3Abdominal intolerance to sugars and starches 0 1 2 3Category IIIIntolerance to smells 0 1 2 3Intolerance to jewelry Intolerance to shampoo, lotion, detergents, etc. 0 1 2 3Multiple smell and chemical sensitivities 0 1 2 3Constant skin outbreaks 0 1 2 3Category IVExcessive belching, burping, or bloating 0 1 2 3Gas immediately following a meal 0 1 2 3Offensive breath 0 1 2 3Difficult bowel movement 0 1 2 3Sense of fullness during and after meals 0 1 2 3Difficulty digesting fruits and vegetables; undigested food found in stools 0 1 2 3Category VStomach pain, burning, or aching 1-4 hours after eating 0 1 2 3Use antacids 0 1 2 3Feel hungry an hour or two after eating 0 1 2 3Heartburn when lying down or bending forward 0 1 2 3Temporary relief by using antacids, food, milk, or carbonated beverages 0 1 2 3Digestive problems subside with rest and relaxation 0 1 2 3Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine 0 1 2 3Category VIRoughage and fiber cause constipation 0 1 2 3Indigestion and fullness last 2-4 hours after eating 0 1 2 3Pain, tenderness, soreness on left side under rib cage 0 1 2 3Excessive passage of gas 0 1 2 3Nausea and/or vomiting 0 1 2 3Stool undigested, foul smelling, mucous like, greasy, or poorly formed 0 1 2 3Frequent urination 0 1 2 3Increased thirst and appetite 0 1 2 3Difficulty losing weight 0 1 2 3Category VIIGreasy or high-fat foods cause distress 0 1 2 3Lower bowel gas and/or bloating several hours after eating 0 1 2 3Bitter metallic taste in mouth, especially in the morning 0 1 2 3Unexplained itchy skin 0 1 2 3Yellowish cast to eyes 0 1 2 3Stool color alternates from clay colored to normal brown 0 1 2 3Reddened skin, especially palms 0 1 2 3Dry or flaky skin and/or hair 0 1 2 3History of gallbladder attacks or stones 0 1 2 3Have you had your gallbladder removed? 0 1 2 3Category VIIIAcne and unhealthy skin 0 1 2 3Excessive hair loss 0 1 2 3Overall sense of bloating 0 1 2 3Bodily swelling for no reason 0 1 2 3Hormone imbalances 0 1 2 3Weight gain 0 1 2 3Poor bowel function 0 1 2 3Excessively foul-smelling sweat 0 1 2 3Category IXCrave sweets during the day 0 1 2 3Irritable if meals are missed 0 1 2 3Depend on coffee to keep going/get started 0 1 2 3Get light-headed if meals are missed 0 1 2 3Eating relieves fatigue 0 1 2 3Feel shaky, jittery, or have tremors 0 1 2 3Agitated, easily upset, nervous 0 1 2 3Poor memory/forgetful 0 1 2 3Blurred vision 0 1 2 3Category XFatigue after meals 0 1 2 3Crave sweets during the day 0 1 2 3Eating sweets does not relieve cravings for sugar 0 1 2 3Must have sweets after meals 0 1 2 3Waist girth is equal or larger than hip girth 0 1 2 3Frequent urination 0 1 2 3Increased thirst and appetite 0 1 2 3Difficulty losing weight 0 1 2 3Category XICannot stay asleep 0 1 2 3Crave salt 0 1 2 3Slow starter in the morning 0 1 2 3Afternoon fatigue 0 1 2 3Dizziness when standing up quickly 0 1 2 3Afternoon headaches 0 1 2 3Headaches with exertion or stress 0 1 2 3Weak nails 0 1 2 3Category XIICannot fall asleep 0 1 2 3Perspire easily 0 1 2 3Under high amount of stress 0 1 2 3Weight gain when under stress 0 1 2 3Wake up tired even after 6 or more hours of sleep 0 1 2 3Excessive perspiration or perspiration with little or no activity 0 1 2 3Category XIIIEdema and swelling in ankles and wrists 0 1 2 3Muscle cramping 0 1 2 3Poor muscle endurance 0 1 2 3Frequent urination 0 1 2 3Frequent thirst 0 1 2 3Crave salt 0 1 2 3Alteration in bowel regularity 0 1 2 3Abnormal sweating from minimal activity 0 1 2 3Inability to hold breath for long periods 0 1 2 3Shallow, rapid breathing 0 1 2 3Category XIVTired/sluggish 0 1 2 3Feel cold―hands, feet, all over 0 1 2 3Require excessive amounts of sleep to function properly 0 1 2 3Gain weight easily 0 1 2 3Increase in weight even with low-calorie diet 0 1 2 3Difficult, infrequent bowel movements 0 1 2 3Depression/lack of motivation 0 1 2 3Morning headaches that wear off as the day progresses 0 1 2 3Outer third of eyebrow thins 0 1 2 3Thinning of hair on scalp, face, or genitals, or excessive hair loss 0 1 2 3Dryness of skin and/or scalp 0 1 2 3Mental sluggishness 0 1 2 3Category XVHeart palpitations 0 1 2 3Inward trembling 0 1 2 3Increased pulse even at rest 0 1 2 3Nervous and emotional 0 1 2 3Insomnia 0 1 2 3Night sweats 0 1 2 3Difficulty gaining weight 0 1 2 3Category XVIDiminished sex drive 0 1 2 3Menstrual disorders or lack of menstruation 0 1 2 3Increased ability to eat sugars without symptoms 0 1 2 3Category XVIIIncreased sex drive 0 1 2 3Tolerance to sugars reduced 0 1 2 3“Splitting” - type headaches 0 1 2 3Category XVIII (Males Only)Urination difficulty or dribbling 0 1 2 3Frequent urination 0 1 2 3Pain inside of legs or heels 0 1 2 3Feeling of incomplete bowel emptying 0 1 2 3Leg twitching at night 0 1 2 3Category XIX (Males Only)Decreased libido 0 1 2 3Decreased number of spontaneous morning erections 0 1 2 3Decreased fullness of erections 0 1 2 3Difficulty maintaining morning erections 0 1 2 3Spells of mental fatigue 0 1 2 3Inability to concentrate 0 1 2 3Episodes of depression 0 1 2 3Muscle soreness 0 1 2 3Decreased physical stamina 0 1 2 3Unexplained weight gain 0 1 2 3Increase in fat distribution around chest and hips 0 1 2 3Sweating attacks 0 1 2 3More emotional than in the past 0 1 2 3Category XX (Menstruating Females Only)Perimenopausal Yes NoAlternating menstrual cycle lengths Yes NoExtended menstrual cycle (greater than 32 days) Yes NoShortened menstrual cycle (less than 24 days) Yes NoPain and cramping during periods 0 1 2 3Scanty blood flow 0 1 2 3Heavy blood flow 0 1 2 3Breast pain and swelling during menses 0 1 2 3Pelvic pain during menses 0 1 2 3Irritable and depressed during menses 0 1 2 3Acne 0 1 2 3Facial hair growth 0 1 2 3Hair loss/thinning 0 1 2 3Category XXI (Menstruating Females Only)How many years have you been menopausal?Since menopause, do you ever have uterine bleeding? Yes NoHot flashes 0 1 2 3Mental fogginess 0 1 2 3Disinterest in sex 0 1 2 3Mood swings 0 1 2 3Depression 0 1 2 3Painful intercourse 0 1 2 3Shrinking breasts 0 1 2 3Facial hair growth 0 1 2 3Acne 0 1 2 3Increased vaginal pain, dryness, or itching 0 1 2 3Part IIIHow many alcoholic beverages do you consume per week?How many caffeinated beverages do you consume per day?How many times do you eat out per week?How many times do you eat raw nuts or seeds per week?Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:Please list all drugs you are currently taking including over the counter drugs, aspirin, etc. Also, list how long you have taken each drug and the condition for which it was prescribed.Medication / Prescribed for / How long(Required)Please type ‘none’ if not applicable.Extra Comments:Please list all vitamins/herbs/supplements you are currently taking. Also, list how much of each supplement you are taking, how long you have taken, and for which condition.Supplement/How much / For / How long(Required)Please type ‘none’ if not applicable.Extra Comments:
