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Name*

Last name

Phone

Your email*

Date of Birth

What are your main concerns?*

Location of Pain:

Quality of Pain:

throbbing

stabbing

hot burning

heavy

shooting

sharp

aching

cramping

How long have you had this pain:

3 months or less

3 – 6 months

12 – 24 months

more than 24 months

How often does this pain occur:

continuously

1 or 2 times a day

several times a day

Several days a week

Less than 4 times a month

Is this pain a result of:

accident

following an operation

cancer treatment

no obvious cause

Other result of pain:

Allergies – please list any known allergies (ex. food, hay fever, pollen, drugs, medication, etc.):

What time do you typically go to sleep?

What time do you typically wake up?

Is it difficult to stay asleep?

Yes

No

Do you wake feeling rested?

Yes

No

Stress Level (1=no stress, 10=high stress)

Major Hospitalizations – please list any hospitalizations (within 1 year) or surgeries:

Other past or current infections (MRSA/ C-Diff, etc.)?

Western Drugs – please list all current prescribed medications

Herbs & Supplements – please list all current herbs & supplements

Diet – please describe any restricted diet you follow now or have in the past:

How is your dental health?

When was your last visit to the dentist?

Do you exercise?

Yes

No

What type of exercise

Exercise times per week

What are your goals for your health?

What are the top 3 priorities in your life?

For the following sections, please check off all symptoms that you are experiencing now or within the past 6 months:

nausea

vomiting

belching

heartburn

bad breath

bleeding gums

ulcers

excessive appetite

gas

abdominal bloating

abdominal pain

decreased appetite

indigestion

low energy / fatigue

crave sweets

decreased ability to taste or smell

diarrhea

constipation

blood in stools / black stools

pus in stools

hemorrhoids

anal fissures

rectal pain

nose bleeds

change in appetite

sweet taste in mouth

often feel pensive / over thinking

edema

recurring sore throat

difficulty swallowing

laryngitis / hoarse voice

frequent urination

urgency to urinate

pain on urination

urine / bowel incontinence

weak urine stream

blood in urine

kidney stones

low back pain

sore / weak knees

crave salty foods

often feel afraid

endometriosis

fibroids/ovarian cysts

frequent urinary tract infections

frequent vaginal infections

pelvic inflammatory disease

abnormal PAP smear

irregular periods

premenstrual syndrome

painful menstrual periods

abnormal bleeding

menopause symptoms

breast lumps

infertility

decreased hearing

ear infections

impotence

premature ejaculation

testicular lumps

prostatitis

genital itching / pain

genital lesions / discharges

decreased libido

ear ringing – low pitch

ear ringing – high pitch

fibrocystic breast

dry eyes

red eyes

eye inflammation

blurred vision

poor night vision

floaters (spots in visual field)

visual changes

glasses / contact lenses

cataracts

crave sour foods

Insomnia

excessive / vivid dreams

grinding teeth

depression

anxiety / stress

Irritability

treated for emotional / psychological problems

indecisiveness

often feel angry

migraine

dizziness

fainting

seizures

localized weakness

numbness or tingling of limbs

tremors

poor coordination

paralysis

aversion to wind

tendonitis

gallstones

high blood pressure

low blood pressure

palpitations

irregular heart beat

chest pain or pressure

jaw, neck, shoulder or arm pain

swollen hands or feet

blood clotting disorders

phlebitis

poor memory

crave bitter foods

excessive joy

fevers

frequent or strong thirst

tend to feel warmer than others

night sweats

chills

cold hands / feet

tend to feel colder than others

cold sweats

headache

neck stiffness

enlarged lymph glands

sweat easily

prefer cold food and drink

prefer warm food and drink

Arthritis

irritable bowel syndrome

menstrual cramps

immune compromised

auto immune disease(s)

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