Date of Birth
Date of Birth
Birth Weight (if known)
Weight One Year Ago
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you had to take off from work or school in the last year?
0 to 2 days
3 to 14 days
more than 15 days
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealth with these concerns in the past?
Have you experienced any success with these approaches?
What other health practitioners are you currently seeing? List name, specialty and phone number.
Please list the date and description of any surgical procedures you have had.
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult?
List any medication you are currently taking:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
Have any other family members had similar problems? (Describe)
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and symptom:
Do you have symptoms immediately after eating, like bloating, gas, sneezing or hives? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:
Are there foods that you crave? If so, please explain:
Describe your diet at the onset of your health concerns:
Do you have any known food allergies or sensitivities?
Describe your "Other" special diet:
What percentage of your meals are home-cooked?
Is there anything else we should know about your current diet, history or relationship to food?
Bowel Movement Frequency
1-3 times per day
more than 3 times per day
not regularly every day
Do you experience intestinal gas? If so, please explain if it is excessive, occassional, odorous, etc:
Regarding your conditions listed above, birefly describe your symptoms, chosen treatment(s), and dates.
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do odors affect you?
Are you or have you been exposed to second-hand smoke?
Do you have mercury amalgam fillings?
Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How do you handle stress?
Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?
How are/were your menses? Do/did you have PMS? Painful periods? If so, please explain.
In the second half of your cycle, do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you/do you still take birth control pills: If so, please list length of time and type.
Have you had any problems with conecption or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.
Do you have any concerns or issues with your sexual functioning that you'd like to share with us? (pain with intercourse, dryness, libido issues, erectile dysfunction)
Is there anything else about your sexual history that would be helpful for us to know in your health history?
How are your moods in general? Do you experience mroe than you would like of anxiety? Depression? Anger?
On a scale of 1–10, one being the worst and 10 being the best, describe your usual level of energy.
At what point in your life did you feel best? Why?
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in your family or on your health care team will be most supportive of you making dietary changes?
Please describe any other information you think would be useful in helping to address your health concern(s):
What are your health goals and aspirations?
Though it may seem odd, please consider why you might want to achieve that for yourself: