WELCOME TO FOUNDATION HEALTH.
Welcome to Foundation Health. We want to have the best possible understanding of your health so that we can provide you with the best possible care. Please complete this questionnaire at your convenience. This information is private. It will not be shared with anyone or any entity, including your insurance company, without your explicit consent. We are providing you with this comprehensive health questionnaire to fill out at your convenience. We know that this form is long. However, in order for us to improve your wellness, we want an understanding of your current health and your health history. While we will ask you for general health updates every time you come into our office, rest assured you will only have to fill out this comprehensive questionnaire once.
Today"s Date
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TELL US ABOUT YOURSELF...
Demographics
Your Name
First Name
Last Name
Nickname/Preferred Name
Date of Birth
-
Month
-
Day
Year
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Height
Weight
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Phone Number
-
Area Code
Phone Number
what kind of phone is this?
Please Select
home
cell
work
Other Phone Number
-
Area Code
Phone Number
E-mail
Preferred Contact Method
Phone
Email
Would you prefer email that we send be encrypted or unencrypted?
Encrypted
Unencrypted
Can we leave confidential medical information on your voicemail?
Yes
No
Please Select
Option 1
Option 2
Option 3
Your Occupation
Emergency Contact Information
First Name
Last Name
Emergency Contact Phone
-
Area Code
Phone Number
What is your ethnicity? (Please check all that apply)
African American
Asian
Caucasian
Hispanic
Mediterranean
Native American
Northern European
Other
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TELL US ABOUT YOUR HEALTH...
Please Rank Your Overall Health
1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
DO YOU HAVE ANY CURRENT HEALTH CONCERNS YOU'D LIKE TO TALK WITH US ABOUT?
Please Select
YES
NO
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CURRENT HEALTH CONCERNS
PROBLEM 1:
DESCRIBE PROBLEM
SEVERITY
Please Select
Mild
Moderate
Severe
TREATMENT APPROACH
TREATMENT SUCCESS?
Please Select
Mildly Successful
Moderately Successful
Severely Successful
PROBLEM 2:
DESCRIBE PROBLEM
SEVERITY
Please Select
Mild
Moderate
Severe
TREATMENT APPROACH
TREATMENT SUCCESS?
Please Select
Mildly Successful
Moderately Successful
Severely Successful
PROBLEM 3:
DESCRIBE PROBLEM
SEVERITY
Please Select
Mild
Moderate
Severe
TREATMENT APPROACH
TREATMENT SUCCESS?
Please Select
Mildly Successful
Moderately Successful
Severely Successful
PROBLEM 4:
DESCRIBE PROBLEM
SEVERITY
Please Select
Mild
Moderate
Severe
TREATMENT APPROACH
TREATMENT SUCCESS?
Please Select
Mildly Successful
Moderately Successful
Severely Successful
PROBLEM 5:
DESCRIBE PROBLEM
SEVERITY
Please Select
Mild
Moderate
Severe
TREATMENT APPROACH
TREATMENT SUCCESS?
Please Select
Mildly Successful
Moderately Successful
Severely Successful
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PAST MEDICAL HISTORY
TELL US ABOUT PAST DIAGNOSES:
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
Illness
Please Select
Alzheimer’s Disease / Dementia
Anemia
Arthritis
Asthma
Autoimmune Disease
Blood Clots
Cancer
Crohn’s Disease or Ulcerative Colitis
Depression / Anxiety
Diabetes
Emphysema / COPD
Epilepsy, convulsions, or seizures
Fibromyalgia
Frequent Urinary Tract Infections
Gout
Heartburn / Acid Reflux / Stomach Ulcers
Heart attack/Angina
Heart failure
Herpes
High cholesterol, triglycerides
High blood pressure (hypertension)
HIV / AIDS
Irritable Bowel Syndrome
Kidney stones
Kidney Disease
Liver Disease
Migraine Headaches
Mononucleosis
Osteoporosis
Parkinson’s Disease
Rheumatic fever
Sinusitis
Sleep apnea
Substance Abuse
Stroke
Thyroid disease
Other (describe)
Date Diagnosed
-
Month
-
Day
Year
Date Picker Icon
Comments
PROVIDE DETAILS FOR ANY POSITIVES INDICATED AND ANY ADDITIONAL PAST MEDICAL HISTORY NOT LISTED:
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PAST SURGICAL HISTORY
HAVE YOU EVER HAD SURGERY?
Please Select
YES
NO
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PAST SURGICAL HISTORY
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
Surgery
Please Select
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Comments
Date of Surgery
-
Month
-
Day
Year
Date Picker Icon
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HOSPITALIZATIONS
HAVE YOU EVER BEEN HOSPITALIZED?
Please Select
YES
NO
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HOSPITALIZATIONS
PLEASE LIST ALL HOSPIATLIZATIONS:
HOSPITAL NAME
DATE
REASON
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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INJURIES
HAVE YOU EVER RECEIVED A BLOOD TRANSFUSION?
Please Select
YES
NO
DO YOU HAVE ANY INJURIES YOU'D LIKE TO TELL US ABOUT?
Please Select
YES
NO
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INJURIES
Injuries
Please Select
Broken Bones (describe)
Head Injury
Neck Injury
Motor Vehicle Accident
Other (describe)
Comments
Date
-
Month
-
Day
Year
Date Picker Icon
Injuries
Please Select
Broken Bones (describe)
Head Injury
Neck Injury
Motor Vehicle Accident
Other (describe)
Comments
Date
-
Month
-
Day
Year
Date Picker Icon
Injuries
Please Select
Broken Bones (describe)
Head Injury
Neck Injury
Motor Vehicle Accident
Other (describe)
Comments
Date
-
Month
-
Day
Year
Date Picker Icon
Injuries
Please Select
Broken Bones (describe)
Head Injury
Neck Injury
Motor Vehicle Accident
Other (describe)
Comments
Date
-
Month
-
Day
Year
Date Picker Icon
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MEDICATIONS
HOW OFTEN HAVE YOU TAKEN ANTIBIOTICS?
>5 TIMES
>5 TIMES
INFANCY/CHILDHOOD
TEEN
HOW OFTEN HAVE YOU TAKEN ORAL STEROIDS (e.g., Cortisone, Prednisone, etc.)?
>5 TIMES
>5 TIMES
INFANCY/CHILDHOOD
TEEN
ARE YOU CURRENTLY TAKING ANY MEDICATION?
Please Select
YES
NO
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MEDICATIONS
WHAT MEDICATIONS ARE YOU CURRENTLY TAKING?
MEDICATION NAME
DATE STARTED
DOSAGE
FREQUENCY
1
2
3
4
5
6
7
8
9
10
IF YOU HAVE ADDITIONAL MEDICATIONS THAT WE SHOULD KNOW ABOUT, PLEASE ATTACH A LIST HERE:
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ALLERGIES
ARE YOU ALLERGIC TO LATEX?
Please Select
YES
NO
DO YOU HAVE SEASONAL ALLERGIES?
Please Select
YES
NO
ARE YOU ALLERGIC TO IODINE?
Please Select
YES
NO
WOULD YOU BE INTERESTED IN HEARING ABOUT ALLERGY DROPS AS A REPLACEMENT TO SHOTS FOR ALLERGY TREATMENT?
Please Select
YES
NO
ARE YOU ALLERGIC TO ANY MEDICATIONS?
Please Select
YES
NO
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ALLERGIES
PLEASE LIST ANY MEDICATION YOU ARE ALLERGIC TO:
MEDICATION NAME
REACTION DESCRIPTION
1
2
3
4
5
6
7
8
9
10
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SUPPLEMENTS, VITAMINS AND MINERALS
ARE YOU TAKING ANY SUPPLEMENTS, VITAMINS OR MINERALS?
Please Select
YES
NO
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SUPPLEMENTS, VITAMINS AND MINERALS
WHAT SUPPLEMENTS ARE YOU CURRENTLY TAKING?
VITAMIN/MINERAL/SUPPLEMENT NAME
DATE STARTED
DOSAGE
FREQUENCY
1
2
3
4
5
6
7
8
9
10
IF YOU WOULD LIKE TO INCLUDE AN ATTACHMENT OF IMAGES OF YOUR SUPPLEMENTS, YOU CAN UPLOAD THEM HERE:
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CHILDHOOD HISTORY
PLEASE ANSWER THE BELOW QUESTIONS:
Yes
No
Don't Know
Were you a full-term baby?
As a child, did you eat a lot of sugar/candy?
Were you a preemie?
Were you breast fed?
Were you bottle fed?
Do you have a history of developmental delay (speech, fine motor/gross motor/learning difficulties)- if yes, please explain below?
Are there any behavioral issues at home or at school?
Do you care to give us additional information about the above answers?
Date of last dental check-up:
-
Month
-
Day
Year
Date Picker Icon
Any dental problems/issues?
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VACCINATIONS
PLEASE ANSWER THE BELOW QUESTIONS
YES
NO
UNSURE
ARE YOUR VACCINATIONS UP TO DATE?
WERE ALL YOUR VACCINATIONS GIVEN IN COLORADO?
DO YOU HAVE QUESTIONS ABOUT VACCINATIONS YOU'D LIKE TO DISCUSS?
PLEASE ATTACH A COPY OF YOUR IMMUNIZATION RECORDS
IF YOU KNOW, HAVE YOU CURRENTLY HAD THE BELOW VACCINATIONS? (IF LEFT BLANK, WE WILL ASSUME YOU ARE NOT UP-TO-DATE)
DATE
Tetanus/Pertussis Vaccine
Influenza Vaccine
Pneumonia Vaccine 23 valent
Pneumonia Vaccine 13 valent
Shingles Vaccine
Hepatitis B Vaccine
Hepatitis A Vaccine
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FAMILY HISTORY
PLEASE TELL US ABOUT THE HEALTH OF YOUR FAMILY:
Father
Mother
Brother/Sister
Brother/Sister
Brother/Sister
Brother/Sister
Good Health
Poor Health
Deceased
Alcoholism
Allergies/Asthma
Alzheimer’s Disease
Autoimmune Disease
Blood Clotting Disorder
Cancer
Depression/Anxiety
Diabetes
Epilepsy
Genetic Disease
Heart Disease
High Cholesterol
Hypertension
Kidney Disease
Stomach Ulcer
PLEASE TELL US ABOUT YOUR FAMILY'S MEDICAL HISTORY:
Child
Child
Child
Child
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Good Health
Poor Health
Deceased
Alcoholism
Allergies/Asthma
Alzheimer’s Disease
Autoimmune Disease
Blood Clotting Disorder
Cancer
Depression/Anxiety
Diabetes
Epilepsy
Genetic Disease
Heart Disease
High Cholesterol
Hypertension
Kidney Disease
Stomach Ulcer
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SOCIAL HISTORY
WITH WHOM DO YOU LIVE?
Name
Age
Relationship
1
2
3
4
5
6
7
8
9
10
PARENTS' RELATIONSHIP
MARRIED
DIVORCED
SEPARATED
MOTHER DECEASED
FATHER DECEASED
BOTH PARENTS DECEASED
WHAT ARE YOUR PARENTS' OCCUPATIONS?
OCCUPATION
MOTHER
FATHER
IN WHAT YEAR WAS YOUR HOME BUILT?
WHAT SCHOOL DO YOU ATTEND?
WHAT GRADE ARE YOU CURRENTLY IN?
TELL US ABOUT YOUR HOBBIES & LEISURE ACTIVITIES:
DO YOU LIVE ON A FARM OR HAVE ANY PETS?
Please Select
YES
NO
WHERE DO YOUR PETS LIVE?
Please Select
INDOOR
OUTDOOR
BOTH
HOW OFTEN DO YOU DO THE FOLLOWING?
ALWAYS
MOST OF THE TIME
SOMETIMES
NEVER
WEAR A SEATBELT
WEAR A HELMET (BIKING, SKIING, SKATING, MOTORCYCLING)
WEAR SUNSCREEN
HAVE YOU EVER TRAVELED OUTSIDE OF THE UNITED STATES?
Please Select
YES
NO
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SOCIAL HISTORY
TELL US WHERE YOU'VE TRAVELED:
COUNTRY
DATES
1
2
3
4
5
6
7
8
9
10
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SOCIAL HISTORY
HAVE YOU OR YOUR FAMILY RECENTLY EXPERIENCED ANY MAJOR LIFE CHANGES?
Please Select
YES
NO
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SOCIAL HISTORY
PLEASE TELL US ABOUT YOUR MAJOR LIFE CHANGES?
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SOCIAL HISTORY
HAVE YOU EXPERIENCED ANY MAJOR LOSSES IN LIFE?
Please Select
YES
NO
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SOCIAL HISTORY
TELL US ABOUT ANY MAJOR LOSSES IN YOUR LIFE:
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SOCIAL HISTORY
HOW IMPORTANT IS RELIGION TO YOU AND YOUR FAMILY
Please Select
NOT AT ALL IMPORTANT
SOMEWHAT IMPORTANT
EXTREMELY IMPORTANT
HOW WELL HAVE THINGS BEEN GOING FOR YOU?
Very Well
Well
Fair
Poorly
Very Poorly
Does not apply
At school
In your job
In your social life
With close friends
With your attitude
With your boyfriend/girlfriend
With your parents
HAVE YOU EVER HAD PSYCHOTHERAPY OR COUNSELING
Please Select
CURRENTLY
PREVIOUSLY
NEVER
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SOCIAL HISTORY
WHAT KIND OF THERAPY/COMMENTS:
IF PREVIOUSLY, PLEASE ENTER THE DATE RANGE:
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SOCIAL HISTORY
Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.
YES
NO
Did you feel safe growing up?
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
Do you currently feel safe in your home?
Do you feel safe, respected and valued in your current relationship?
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
Would you feel safer discussing any of these issues privately?
HAVE YOU EVER USED ALCOHOL?
Please Select
YES
NO
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SOCIAL HISTORY
HOW OFTEN DO YOU DRINK ALCOHOL?
Please Select
No longer drinking alcohol
Average 1-3 drinks per week
Average 4-6 drinks per week
Average 7-10 drinks per week
Average >10 drinks per week
HAVE YOU EVER HAD A PROBLEM WITH ALCOHOL OR NEEDED TO DECREASE THE AMOUNT YOU DRINK?
Please Select
YES
NO
MAYBE
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SOCIAL HISTORY
HAVE YOU EVER USED RECREATIONAL DRUGS?
Please Select
YES
NO
DO YOU EVER SPEND TIME IN A PLACE WHERE PEOPLE SMOKE OR LIVE WITH ANYONE WHO SMOKES?
Please Select
YES
NO
HAVE YOU EVER USED TOBACCO?
Please Select
YES
NO
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SOCIAL HISTORY
NUMBER OF YEARS AS A NICOTINE USER
YEAR QUIT
AMOUNT PER DAY
TYPE OF NICOTINE
Please Select
Cigarettes
Smokeless
Cigar
Pipe
Patch/Gum
Other
ARE YOU REQULARLY EXPOSED TO SECOND-HAND SMOKE?
Please Select
YES
NO
MAYBE
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YOU'RE MORE THAN HALFWAY DONE!
Thank you for taking the time to fill this out. Your health is worth it!
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DIETARY HISTORY
TELL US ABOUT A TYPICAL MEAL FOR YOU
BREAKFAST
LUNCH
DINNER
SNACK(S)
Bacon/Sausage
Bagel
Beans (legumes)
Brown rice
Butter
Carrots
Cereal
Coffee
Donut
Eat in a cafeteria
Eat in restaurant
Eggs
Fish
Fruit
Green vegetables
Juice
Leftovers
Lettuce
Margarine
Mayo
Meat sandwich
Milk
None
Oat bran
Pasta
Potato
Poultry
Red meat
Rice
Salad
Salad dressing
Soda
Soup
Sugar
Sweet roll
Artificial Sweetener
Tea
Toast
Tomato
Water
Wheat bran
Yellow vegetables
Yogurt
Other (List Below)
PLEASE LIST ANYTHING ELSE THAT YOU EAT FREQUENTLY:
HOW MUCH OF THE FOLLOWING DO YOU EAT EACH WEEK?
LESS THAN 1 TIME/WEEK
1-2 TIMES/WEEK
3-5 TIMES/WEEK
6-10 TIMES/WEEK
10+ TIMES/WEEK
Candy
Cheese
Chocolate
Cups of coffee containing caffeine
Cups of decaffeinated coffee or tea
Cups of hot chocolate
Cups of tea containing caffeine
Diet sodas
Ice cream
Salty foods
Slices of white bread (rolls/bagels)
Sodas with caffeine
Sodas without caffeine
ARE YOU ON A SPECIAL DIET?
blood type diet
dairy restricted
diabetic
gluten-free
ovo-lacto
vegan
vegetarian
Other
WHAT ARE YOUR DIET AND NUTRITION GOALS?
PLEASE TELL US ABOUT YOUR FOOD ALLERGIES:
IF YOU WOULD LIKE TO GO MORE IN DEPTH WITH US ABOUT YOUR DIET, PLEASE PROVIDE A 3 TO 5-DAY FOOD LOG HERE.
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DO YOU HAVE A HISTORY OF SKIPPING MEALS, PURGING OR RESTRICTING FOOD INTAKE?
YES
NO
DON'T KNOW
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EXERCISE HISTORY
HOW MANY TIMES DO YOU EXERCISE PER WEEK?
Please Select
1
2
3
4
5
6
7+
WHEN YOU EXERCISE, HOW LONG IS EACH SESSION?
Please Select
LESS THAN 15 MINUTES
16-30 MINUTES
31-45 MINUTES
MORE THAN 45 MINUTES
WHAT KIND OF EXERCISE IS IT?
Please Select
Jogging
Walking
Running
Tennis
Basketball
Water Sports
Aerobics
Yoga
Weightlifting
Other
WHAT ARE YOUR EXERCISE GOALS?
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TOXIN/ENVIRONMENTAL EXPOSURE HISTORY
DO YOU HAVE MERCURY AMALGAM FILLINGS?
Please Select
YES
NO
DO YOU HAVE ARTIFICIAL JOINTS OR IMPLANTS?
Please Select
YES
NO
HAVE YOU BEEN EXPOSED TO TOXIC MATERIALS AT YOUR HOME, TO YOUR KNOWLEDGE?
Please Select
lead
cadmium
arsenic
mercury
aluminum
DO ODORS AFFECT YOU?
Please Select
YES
NO
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GENERAL CONCERNS
GENERAL HEALTH
Mild
Moderate
Severe
Cold hands & feet
Cold intolerance
Daytime sleepiness
Difficulty falling asleep
Early waking
Fatigue
Fever
Flushing
Heat intolerance
Night waking
Nightmares
No dream recall
HEAD, EYES, EARS
Mild
Moderate
Severe
Conjunctivitis
Distorted sense of smell
Distorted taste
Ear fullness
Ear noises
Ear pain
Ear ringing/buzzing
Eye crusting
Eye pain
Headache
Hearing loss
Hearing problems
Lid margin redness
Migraine
Sensitivity to loud noises
Vision problems
MUSCULOSKELETAL
Mild
Moderate
Severe
Back muscle spasm
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint pain
Joint redness
Joint stiffness
Muscle pain
Muscle spasms
Muscle stiffness
Muscle twitches around eyes
Muscle twitches around arms or legs
Muscle weakness
Neck muscle spasm
Tendonitis
Tension headache
TMJ problems
MOOD/NERVES
Mild
Moderate
Severe
Agoraphobia
Anxiety
Auditory hallucinations
Black-out
Depression
Difficulty Concentrating
Difficulty with balance
Difficulty with thinking
Difficulty with judgment
Difficulty with speech
Difficulty with memory
Dizziness (spinning)
Fainting
Fearfulness
Irritability
Light-headedness
Numbness
Other Phobias
Panic attacks
Paranoia
Seizures
Suicidal thoughts
Tingling
Tremor/trembling
Visual hallucinations
EATING
Mild
Moderate
Severe
Binge eating
Bulimia
Can't gain weight
Can't lose weight
Carbohydrate craving
Carbohydrate intolerance
Poor appetite
Salt craving
DIGESTION
Mild
Moderate
Severe
Anal spasms
Bad teeth
Bleeding gums
Bloating of Lower abdomen"
Bloating oF Whole abdomen
Blood in stools
Burping
Canker sores
Cold sores
Constipation
Cracking at corner of lips
Dentures w/poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Farting
Fissures
Foods "repeat" (reflux)
Heartburn
Hemorrhoids
Intolerance to Lactose
Intolerance to all milk products
Intolerance to gluten (wheat)
Intolerance to corn
Intolerance to eggs
Intolerance to fatty foods
Intolerance to yeast
Liver disease/jaundice (yellow eyes or skin)
Lower abdominal pain
Mucus in stools
Nausea
Periodontal disease
Sore tongue
Strong stool odor
Undigested food in stools
Upper abdominal pain
Vomiting
SKIN PROBLEMS
Mild
Moderate
Severe
Acne on back
Acne on chest
Acne on face
Acne on shoulders
Athlete’s foot
Bumps on back of upper arms
Cellulite
Dark circles under eyes
Ears get red
Easy bruising
Eczema
Herpes - genital
Hives
Jock itch
Lackluster skin
Moles w color/size change
Oily skin
Pale skin
Patchy dullness
Psoriasis
Rash
Red face
Sensitive to bites
Sensitive to poison ivy/oak
Shingles
Skin cancer
Skin darkening
Strong body odor
Thick calluses
Vitiligo
SKIN ITCHING
Mild
Moderate
Severe
Anus
Arms
Ear canals
Eyes
Feet
Hands
Legs
Nipples
Nose
Penis
Roof of mouth
Scalp
Skin in general
Throat
DRYNESS OF SKIN
Mild
Moderate
Severe
Eyes
Feet
Cracking Feet
Peeling Feet
Dry Hair
Unmanageable Hair
Dry Hands
Cracking on Hands
Peeling on Hands
Dry Mouth/throat
Dry Scalp
Dandruff?
Dry Skin in general
LYMPH NODES
Mild
Moderate
Severe
Enlarged neck
Tender neck
Other enlarged
Tender lymph nodes
NAILS
Mild
Moderate
Severe
Bitten Nails
Brittle Nails
Nails curve up
Frayed Nails
Fungus - fingers
Fungus – toes
Pitting
Ragged cuticles
Ridges
Soft
Thickening of Finger nails
Thickening of Toenails
White spots/lines
RESPIRATORY
Mild
Moderate
Severe
Bad breath
Bad odor in nose
Cough - dry
Cough - productive
Spring Hay fever
Summer Hay fever
Fall Hay fever
Change of season Hay fever
Hoarseness
Nasal stuffiness
Nose bleeds
Post nasal drip
Sinus fullness
Sinus infection
Snoring
Sore throat
Wheezing
Winter stuffiness
CARDIOVASCULAR
Mild
Moderate
Severe
Angina/chest pain
Breathlessness
Heart attack
Heart murmur
High blood pressure
Irregular pulse
Mitral valve prolapse
Palpitations
Phlebitis
Swollen ankles/feet
Varicose veins
URINARY
Mild
Moderate
Severe
Bed wetting
Hesitancy
Infection
Kidney disease
Kidney stone
Leaking/incontinence
Pain/burning
Prostate enlargement
Prostate infection
Urgency
ARE YOU MALE OR FEMALE?
Please Select
MALE
FEMALE
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FEMALE REPRODUCTIVE
AGE AT FIRST PERIOD
HAVE YOU EVER TAKEN BIRTH CONTROL PILLS?
Please Select
CURRENTLY
PREVIOUSLY
NEVER
DO YOU CURRENTLY USE CONTRACEPTION?
Please Select
YES
NO
IF YES, WHAT KIND?
IF YES, WHEN DID YOU LAST GET YOUR PERIOD?
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TREATING PHYSICIANS/ WELLNESS PROVIDERS
PLEASE LIST ALL (PAST AND PRESENT) PROVIDERS AND THEIR CONTACT INFORMATION WHO MAY HAVE PERTINENT RECORDS FOR US TO REQUEST.
FIRST NAME
LAST NAME
CITY
STATE
PHONE NUMBER
PROVIDER 1
PROVIDER 2
PROVIDER 3
PROVIDER 4
PROVIDER 5
PROVIDER 6
PROVIDER 7
PROVIDER 8
PROVIDER 9
PROVIDER 10
PLEASE ATTACH ADDITIONAL PROVIDERS YOU'D LIKE US TO SPEAK WITH HERE:
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THANK YOU FOR HELPING US PROVIDE YOU WITH EXCEPTIONAL PRIMARY CARE!
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