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HIRSCH HOLISTIC FAMILY MEDICINE ADULT MEDICAL QUESTIONNAIRE 3525 Ensign Rd NE, Suite N | Olympia, WA 98506 | Ph: (360) 464-9965 | Fax (Toll Free): 1-888-897-8320

Please return this packet no later than 48 hours prior to your appointment.

Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing

them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan.

Patient’s Full Name: Today’s Date:

☐ Black or African American ☐ Hispanic or Latino ☐ Native Hawaiian / Pacific Islander ☐ Asian

☐ American Indian ☐ Alaskan Native ☐ Pacific Islander ☐ White ☐ Other

HISTORY OF PRESENT ILLNESS What are the medical problems you would like addressed? Please rank in order of priority.

Describe Current & Ongoing Problem M

ild

Mo

der

ate

Sev

ere

Prior Treatment or

Approach

SUCCESS

Go

od

Fai

r

Po

or

Example: Post Nasal Drip ☐ ☒ ☐ Elimination Diet ☐ ☒ ☐

☐ ☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐ ☐

☐ ☐ ☐ ☐ ☐ ☐

In general, would you say your health is: ☐ Excellent ☐ Very Good ☐ Good ☐ Fair ☐ Poor

Compared to one year ago, how would you rate your health in general now?

☐ Much better ☐ Somewhat better ☐ About the same ☐ Somewhat worse ☐ Much worse

What do you hope to achieve in your visit with us? When was the last time you felt well? Did something trigger your change in health? What makes you feel worse? What makes you feel better?

During the past 4 weeks, to what extent has your physical or emotional health interfered with your normal activities?

☐ Not at all ☐ Slightly ☐ Moderately ☐ Quite a bit ☐ Extremely

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How TRUE or FALSE is each of the following statements for you? Definitely

True Mostly True

Don’t Know

Mostly False

Definitely False

I seem to get sick a little easier than other people.

I am as healthy as anybody I know

I expect my health to get worse

My health is excellent

Childhood Yes No Don’t Know

Comment

Were you a full term baby? ☐ ☐ ☐

A preemie? ☐ ☐ ☐

Breast fed? ☐ ☐ ☐

Bottle fed? ☐ ☐ ☐

Was your birth spontaneous or induced? ☐ ☐ ☐

Caesarean-birth? ☐ ☐ ☐

Delivered in a US hospital? Where? ☐ ☐ ☐

Were you vaccinated as a child? ☐ ☐ ☐

As a child did you eat a lot of sugar and/or candy? ☐ ☐ ☐

Did you ever take abuse as a child? ☐ ☐ ☐

Did you feel safe as a child? ☐ ☐ ☐

Were you a “sick” or “healthy” child? ☐ ☐ ☐

Were you under a lot of stress as a child? ☐ ☐ ☐

Where did you grow up?

As a child, were there any foods that you had to avoid because they gave you symptoms? ☐ Yes ☐ No

If yes, please name the food and symptom (Example: milk – gas and diarrhea):

REVIEW OF SYSTEMS Please check if these symptoms occur presently or have occurred in the past 6 months.

SKIN PROBLEMS

☐ Acne on Back / Chest / Face / Shoulders

☐ Athlete’s Foot

☐ Bumps on Back of Upper Arms

☐ Cellulite

☐ Dark Circles Under Eyes

☐ Ears Get Red

☐ Easy Bruising

☐ Lack of Sweating

☐ Eczema

☐ Herpes-Genital

☐ Hives

☐ Jock Itch

☐ Lackluster Skin

☐ Moles w/ Color or Size Change

☐ Oily Skin

☐ Pale Skin

☐ Patchy Dullness

☐ Rash

☐ Red Face

☐ Sensitive to Bites

☐ Sensitive to Poison Ivy / Oak

☐ Shingles

☐ Skin Darkening

☐ Strong Body Odor

☐ Hair Loss

☐ Vitiligo

ITCHING SKIN

☐ Skin in General

☐ Anus

☐ Arms

☐ Ear Canals

☐ Eyes

☐ Feet

☐ Hands

☐ Legs

☐ Nipples

☐ Nose

☐ Penis

☐ Roof of Mouth

☐ Scalp

☐ Throat

SKIN, DRYNESS OF

☐ Skin in General

☐ Eyes

☐ Feet

☐ and Cracking?

☐ and Peeling?

☐ Hair

☐ and Unmanageable?

☐ Hands

☐ and Cracking?

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☐ and Peeling?

☐ Mouth / Throat

☐ Scalp

☐ and Dandruff?

NAILS

☐ Bitten

☐ Brittle

☐ Curve Up

☐ Frayed

☐ Fungus-Fingers

☐ Fungus-Toes

☐ Pitting

☐ Ragged Cuticles

☐ Ridges

☐ Soft

Thickening of:

☐ Finger Nails

☐ Toenails

☐ White Spots/Lines

EARS

☐ Earaches, ear infections

☐ Drainage from ear

☐ Ringing in ears, hearing loss

EYES

☐ Watery

☐ Swollen, reddened or sticky eyelids

☐ Bags or dark circles under eyes

☐ Blurred or tunnel vision

HEAD

☐ Headaches

☐ Faintness

☐ Dizziness

MOUTH / THROAT

☐ Gagging, frequent need to clear throat

☐ Sore throat, hoarseness, loss of voice

☐ Swollen/discolored tongue, gum, lips

☐ Canker sores

RESPIRATORY

☐ Asthma, bronchitis

☐ Bad Breath

☐ Bad Odor in Nose

☐ Chest congestion

☐ Cough-Chronic

☐ Cough-Dry

☐ Cough-Productive

☐ Difficulty breathing

☐ Excessive mucus formation

☐ Hoarseness

☐ Sore Throat

Hay Fever:

☐ Spring

☐ Summer

☐ Fall

☐ Winter

☐ Nasal Stuffiness

☐ Nose Bleeds

☐ Post Nasal Drip

☐ Sinus Fullness

☐ Sinus Infection

☐ Shortness of breath

☐ Sneezing attacks

☐ Snoring

☐ Wheezing

☐ Winter Stuffiness

LYMPH NODES

☐ Enlarged/neck

☐ Tender/neck

☐ Other Enlarged/Tender

CARDIOVASCULAR

☐ Angina / Chest Pain

☐ Breathlessness

☐ Heart Murmur

☐ Irregular Pulse

☐ Palpitations

☐ Phlebitis

☐ Swollen Ankles / Feet

☐ Varicose Veins

URINARY

☐ Bed Wetting

☐ Hesitancy (trouble getting started)

☐ Infection

☐ Kidney Disease

☐ Leaking / Incontinence

☐ Pain / Burning

☐ Urinary Infection

☐ Urgency

DIGESTIVE TRACT

☐ Nausea or vomiting

☐ Diarrhea

☐ Constipation

☐ Bloated feeling

☐ Belching, or passing gas

☐ Heartburn

☐ Intestinal / Stomach pain

JOINTS / MUSCLES

☐ Pains or aches in joints

☐ Arthritis

☐ Stiffness or limitation of movement

☐ Pain or aches in muscles

☐ Feeling of weakness or tiredness

WEIGHT

☐ Binge eating / drinking

☐ Craving certain foods

☐ Excessive weight

☐ Compulsive eating

☐ Water retention

☐ Underweight

ENERGY / ACTIVITY

☐ Fatigue, sluggishness

☐ Apathy, lethargy

☐ Hyperactivity

☐ Restlessness

EMOTIONS

☐ Mood swings

☐ Anxiety, fear, or nervousness

☐ Anger, irritability, or aggressiveness

☐ Depression

MIND

☐ Poor Memory

☐ Confusion, poor comprehension

☐ Poor concentration

☐ Poor physical coordination

☐ Difficulty in making decisions

☐ Stuttering or stammering

☐ Slurred speech

☐ Learning disabilities

MALE REPRODUCTIVE

☐ Discharge from Penis

☐ Ejaculation Problem

☐ Genital Pain

☐ Impotence

☐ Prostate Infection

☐ Lumps in Testicles

☐ Poor Libido (Sex Drive)

FEMALE REPRODUCTIVE

☐ Breast Cysts

☐ Breast Lumps

☐ Breast Tenderness

☐ Ovarian Cyst

☐ Poor Libido (Sex Drive)

☐ Vaginal Discharge

☐ Vaginal Odor

☐ Vaginal Itch

☐ Vaginal Pain with Sex

Premenstrual:

☐ Bloating Breast Tenderness

☐ Carbohydrate Cravings

☐ Chocolate Cravings

☐ Constipation

☐ Decreased Sleep

☐ Diarrhea

☐ Fatigue

☐ Increased Sleep

☐ Irritability

Menstrual:

☐ Cramps

☐ Heavy Periods

☐ Irregular Periods

☐ No Periods

☐ Scanty Periods

☐ Spotting Between

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PERSONAL MEDICAL HISTORY

Date of last full physical exam: Provider:

Please list past and current medical conditions / diagnoses received:

ILLNESSES AND DIAGNOSES WHEN COMMENTS

INJURIES WHEN COMMENTS

DIAGNOSTIC STUDIES (CT, EKG, etc.)

WHEN COMMENTS

OPERATIONS WHEN COMMENTS

HOSPITALIZATIONS WHERE/WHEN REASON

PREVENTIVE TESTS (DEXA scan, ultrasound, mammogram, etc.)

WHEN REASON

BLOOD TYPE

☐ A ☐ B ☐ AB ☐ O ☐ Rh+ ☐ Unknown

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WOMEN’S HISTORY (for women only):

Have you ever been pregnant? ☐ Yes ☐ No

Number of miscarriages Number of abortions Number of preemies Number of term births Birth weight of largest baby and of smallest baby

Did you develop toxemia (high blood pressure)? ☐ Yes ☐ No

Have you had other problems with pregnancy? ☐ Yes ☐ No

If so, please comment: Age at first period Date of last Pap Smear Date of last Mammogram

Pap Smear: ☐ Normal ☐ Abnormal

Mammogram: ☐ Normal ☐ Abnormal

Have you ever used birth control pills? ☐ Yes ☐ No If yes, when

Are you taking the pill now? ☐ Yes ☐ No

Did taking the pill agree with you? ☐ Yes ☐ No ☐ Not applicable

Do you currently use contraception? ☐ Yes ☐ No

If yes, what type of contraception do you use?

Are you in menopause? ☐ Yes ☐ No If yes, age at last period______

Do you take: ☐ Estrogen? ☐ Ogen? ☐ Estrace? ☐ Premarin? ☐ Other (specify)

☐ Progesterone? ☐ Provera? ☐ Other (specify)

How long have you been on hormone replacement therapy (if applicable)? In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)?

☐ Yes ☐ No ☐ Not applicable

MEN’S HISTORY (for men only):

Have you had a PSA done? ☐ Yes ☐ No PSA Level: ☐ 0-2 ☐ 2-4 ☐ 4-10 ☐ 10+

☐ Prostate Enlargement ☐ Prostate Infection ☐ Change in Libido ☐ Impotence

☐ Difficulty Obtaining an Erection ☐ Difficulty Maintaining an Erection

☐ Nocturia (urination at night) How many times at night?

☐ Urgency/Hesitancy/Change in Urinary Stream ☐ Loss of Control of Urine

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SOCIAL TRAVEL

Have you lived or traveled outside of the United States? ☐ Yes ☐ No

If so, when and where?

DENTAL

Have you ever had dental surgery? ☐Yes ☐ No When? What kind?

Do you have mercury amalgam fillings? ☐Yes ☐ No How many? For how long?

ANTIBIOTICS & STEROIDS

How often have you have taken antibiotics? Less than 5x More than 5x

Infancy/ Childhood ☐ ☐

Teen ☐ ☐

Adulthood ☐ ☐

How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?

Less than 5x More than 5x

Infancy/ Childhood ☐ ☐

Teen ☐ ☐

Adulthood ☐ ☐

RECREATIONAL DRUGS

Are you currently using any recreational drugs? ☐Yes ☐ No Type:

Have you ever used IV or inhaled recreational drugs? ☐Yes ☐ No

TOBACCO

Have you ever used tobacco? ☐ Yes ☐ No

If yes, number of years as a nicotine user: Amount per day: Year quit:

If yes, what type of nicotine have you used? ☐ Cigarette ☐ Smokeless ☐ Patch/Gum

☐ Cigar ☐ Pipe ☐ e-Cigarette

Are you (or were you) exposed to second hand smoke regularly? ☐ Yes ☐ No

ALCOHOL

Have you ever used alcohol? ☐ Yes ☐ No

If yes, how often do you now drink alcohol? Drinks per ☐ Day ☐ Week ☐ Month ☐ Year

If yes, please also answer the following:

Yes No

☐ ☐ Have you ever been told you should cut down your alcohol intake?

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Yes No

☐ ☐ Do you get annoyed when people ask you about your drinking?

☐ ☐ Do you ever feel guilty about consumption of alcohol?

☐ ☐ Do you ever take an eye-opener? (an alcoholic drink first thing in the morning)

☐ ☐ Do you notice a tolerance to alcohol (can you “hold” more than others)?

☐ ☐ Have you ever been unable to remember a drinking episode?

☐ ☐ Do you get into arguments or physical fights when you have been drinking?

☐ ☐ Have you ever been arrested or hospitalized because of your drinking?

☐ ☐ Have you ever thought about getting help to control or stop your drinking?

CAFFEINE

Caffeine intake: ☐ Yes ☐ No Cups/day: ☐ Coffee ☐ Tea ☐Other:

Do you have an adverse reaction to caffeine? ☐ Yes ☐ No If yes, what reaction?

When you drink caffeine do you feel: ☐ Irritable or Wired? ☐ Aches & Pains?

WATER How much water do you drink per day? EXERCISE

Do you exercise regularly? ☐ Yes ☐ No

If so, how many times a week? When you exercise, how long is each session?

☐ 1x ☐ 15 min or less

☐ 2x ☐ 16-30 min

☐ 3x ☐ 31-45 min

☐ 4x or more ☐ More than 45 min

What type of exercise is it?

Flexibility and Range of Motion

Strengthening and Resistance

Cardiovascular and Aerobic

☐ Yoga ☐ Curl-ups (Sit-ups) ☐ Jogging

☐ Tai Chi ☐ Push-ups ☐ Walking

☐ Stretching ☐ Weight Training ☐ Aerobics

☐ Other (Specify): ☐ Other (Specify): ☐ Swimming

☐ Other (Specify)

☐

Is playing sports a part of your regular exercise? ☐ Yes ☐ No

If so, which sport(s)?

LOSS

Have you experienced any major losses in life? ☐ Yes ☐ No

If so, please comment:

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STRESS

Have you or your family recently experienced any major life changes? ☐ Yes ☐ No

If yes, please comment:

Are you happy? ☐ Yes ☐ No

Do you feel your life has meaning and purpose? ☐ Yes ☐ No

Do you believe stress is presently reducing the quality of your life? ☐ Yes ☐ No

Do you feel you have an excessive amount of stress in your life? ☐ Yes ☐ No

Do you feel you can easily handle the stress in your life? ☐ Yes ☐ No

Daily Stressors (Rate the intensity of each on a scale of 1-10, with 10 being the most stressful) Work: Family: Social: Finance: Health: Other:

COPING STRATEGIES

Do you practice meditation or a relaxation technique? ☐ Yes ☐ No How often?

Check all that apply: ☐ Yoga ☐ Meditation ☐ Imagery ☐ Breathing ☐ Tai Chi

☐ Prayer ☐ Other

Have you ever had psychotherapy or counseling? ☐Yes ☐ No

☐ Currently? ☐ Previously? If previously, from to .

What kind of therapy? Provider? Comments:

SLEEP

Average number of hours you sleep per night: ☐ 10+ ☐ 8-10 ☐ 6-8 ☐ less than 6

Do you have trouble falling asleep? ☐ Yes ☐ No ☐ Sometimes

Do you feel rested upon awakening? ☐ Yes ☐ No ☐ Sometimes

Do you have problems with insomnia? ☐ Yes ☐ No ☐ Sometimes

Do you snore? ☐ Yes ☐ No ☐ Sometimes

Do you ever use sleeping aids? ☐ Yes ☐ No Explain:

Do you have morning headaches? ☐ Yes ☐ No ☐ Sometimes

Do you wake up during the night? ☐ Yes ☐ No ☐ Sometimes How many times per night?

To urinate? ☐ Yes ☐ No Other reason?

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RELATIONSHIPS With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)

Example: Wendy, age 7, sister

Are you currently, or have you ever been, married or in a long-term relationship? ☐Yes ☐ No

If so, when did your relationship begin? Spouse/Partner occupation:

Have you separated? ☐Yes ☐ No If so, when?

Have you divorced? ☐Yes ☐ No If so, when?

Have you had any other previous marriages/long-term relationships? ☐Yes ☐ No

Comments:

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.

Please do your best to answer the following questions:

Have you been involved in abusive relationships in your life?

☐ Yes ☐ No

Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?

☐ Yes ☐ No

Do you currently feel safe in your home?

☐ Yes ☐ No

Do you feel safe, respected and valued in your current relationships?

☐ Yes ☐ No

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?

☐ Yes ☐ No

Would you feel safer discussing any of these issues face-to-face instead of on paper?

☐ Yes ☐ No

SEXUAL Do you believe that your sexual activity is appropriate for you during this stage of your life? Do you have any challenges having sex? (e.g. pain, performance, or intimacy issues)

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ENVIRONMENTAL TOXINS

Do you feel worse at certain times of the year? ☐ Yes ☐ No

If yes, when? ☐ Spring ☐ Fall ☐ Summer ☐ Winter

Have you, to your knowledge, been exposed to toxic metals in your job or at home? ☐ Yes ☐ No

Do odors affect you? ☐ Yes ☐ No

Do you adversely react to (check all that apply):

☐ Monosodium glutamate (MSG) ☐Bananas ☐ Caffeine ☐ Aspartame (Nutrasweet)

☐ Garlic ☐ Onions ☐ Cheese ☐ Citrus

☐ Preservatives (ex. sodium benzoate) ☐ Alcohol ☐ Red wine ☐ Other:

☐ Sulfite containing foods (wine, dried fruit, salad bars)

Which of these significantly affects you? (check all that apply):

☐ Cigarette Smoke ☐ Perfumes/Colognes ☐ Auto exhaust fumes ☐ Other:

In your work or home environment, are you exposed (or have you been exposed) to:

☐ Chemicals ☐ Electromagnetic Radiation ☐ Mold

If chemicals, which one(s)?

☐ Lead ☐ Cadmium

☐ Arsenic ☐ Mercury

☐ Aluminum

Have you ever turned yellow (jaundiced)? ☐ Yes ☐ No

Have you ever been told you have Gilbert’s syndrome or a liver disorder? ☐ Yes ☐ No

Explain:

Do you have a known history of significant exposure to any harmful chemicals such as the following:

☐ Herbicides ☐ Insecticides (frequent visits of exterminator) ☐ Pesticides ☐ Organic Solvents

☐ Heavy metals ☐ Other

Chemical name(s), date(s), length of exposure:

Do you dry clean your clothes frequently? ☐ Yes ☐ No

Do you or have you lived or worked in a damp or moldy environment or had other mold exposures? ☐ Yes ☐ No

Have you ever had any water damage (ex. broken pipe or flooding) in your house? ☐ Yes ☐ No When?

Has your house ever been tested for mold? ☐ Yes ☐ No

Do you ever come home and your house smells “musty”? ☐ Yes ☐ No

Do you have any pets or farm animals? ☐ Yes ☐ No If yes, where do they live? ☐ Indoors ☐ Outdoors

Do you have carpeting? ☐ Yes ☐ No A wood stove? ☐ Yes ☐ No Wood Paneling? ☐ Yes ☐ No

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SPIRITUAL How important is religion (or spirituality) for you and your family’s life?

☐ Not at all important ☐ Somewhat important ☐ Extremely important

How do you connect with spirit? Do you believe in God?

WORK Current occupation: Do you like the work you do?

Do you spend the majority of your time and money fulfilling responsibilities and obligations? ☐Yes ☐ No

How much time have you lost from work or school in the past year? ☐ 0-2 days ☐ 3 –14 days ☐ More than 15 days

Previous jobs: PLAY What do you do for fun? Hobbies and leisure activities: What is your bliss or joy? DIET

Are you on a special diet? ☐ Yes ☐ No

☐ Ovo-lacto ☐ Vegetarian ☐ Gluten Free/Dairy Free

☐ Diabetic ☐ Vegan ☐ Paleo

☐ Dairy-restricted ☐ Blood type diet ☐ Other (describe):

Is there anything special about your diet that we should know? ☐ Yes ☐ No

If yes, please explain:

Do you currently have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? ☐ Yes ☐ No

If yes, are these symptoms associated with any particular food or supplement(s)? ☐ Yes ☐ No

Please name the food or supplement and symptom(s). (Example: milk – gas and diarrhea.)

Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such

as fatigue, muscle aches, sinus congestion, etc.? ☐ Yes ☐ No

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Do you feel much worse when you eat a lot of :

☐ High fat foods ☐ Refined sugar (junk food)

☐ High protein foods ☐ Fried foods

☐ High carbohydrate foods ☐ 1 or 2 alcoholic drinks

(Breads, pastas, potatoes) ☐ Other

Do you feel much better when you eat a lot of :

☐ High fat foods ☐ Refined sugar (junk food)

☐ High protein foods ☐ Fried foods

☐ High carbohydrate foods ☐ 1 or 2 alcoholic drinks

(Breads, pastas, potatoes) ☐ Other

Does skipping a meal greatly affect your symptoms? ☐ Yes ☐ No

Have you ever had a food that you craved or really "binged" on over a period of time? ☐ Yes ☐ No Food craving may be an indicator that you may be allergic to that food. If yes, what food(s)? __________________________________________________________________________

Do you have an aversion to certain foods? ☐ Yes ☐ No

If yes, what foods?

BOWEL MOVEMENTS Please fill in the chart below with information about your bowel movements:

Frequency Color Consistency More than 3x/day ☐ Medium brown consistently ☐ Soft and well formed ☐

1-3x/day ☐ Very dark or black ☐ Often float ☐

4-6x/week ☐ Greenish color ☐ Difficult to pass ☐

2-3x/week ☐ Blood is visible. ☐ Diarrhea ☐

1 or fewer x/week ☐ Varies a lot. ☐ Thin, long or narrow ☐

Dark brown consistently ☐ Small and hard ☐

Yellow, light brown ☐ Loose but not watery ☐

Greasy, shiny appearance ☐ Alternating between hard and loose/watery

☐

Intestinal gas: ☐ Daily ☐ Present with pain

☐ Occasionally ☐ Foul smelling

☐ Excessive ☐ Little odor

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MOTIVATION Rate on a scale of 5 (very willing) to 1 (not willing) In order to improve your health, how willing are you to:

Significantly modify your diet ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Take several nutritional supplements each day ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Keep a record of everything you eat each day ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Modify your lifestyle (e.g., work demands, sleep habits) ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Practice a relaxation technique ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Engage in regular exercise ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Have periodic lab tests to assess your progress ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1

Comments:

FAMILY HISTORY Please indicate only blood relatives.

Current Age (or age at death, if deceased)

Good health currently?

Known Health Issues

Mother

Father

Brothers

Sisters

Children

Grandmothers

Grandfathers

Uncles & Aunts

Other

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ALLERGIES

Are you allergic to any medications or supplements? ☐ Yes ☐ No

If yes, please list:

Are you allergic to any foods? ☐ Yes ☐ No

If yes, please list:

MEDICATIONS What medications are you taking now? Include non-prescription drugs.

Medication Name Date started Dose/Frequency Reason for Use

SUPPLEMENTS List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.

Vitamin/Mineral/Supplement Name Date started Dose/Frequency Reason for Use

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3-DAY DIET DIARY INSTRUCTIONS It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.

Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.

Record information as soon as possible after the food has been consumed

Describe the food or beverage as accurately as possible e.g., milk – what kind? (whole, 2%, nonfat); toast – (whole wheat, white, buttered); chicken – (fried, baked, breaded), coffee – (decaffeinated with sugar and half-n-half).

Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, ½ cup, 1 teaspoon, etc.

Include any added items. For example: tea with 1 teaspoon honey; potato with 2 teaspoons butter, etc.

Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.

Include any additional comments about your eating habits on this form (ex. craving sweets, skipped meals and why, when the meal was at a restaurant, etc).

Please note all bowel movements and their consistency (regular, loose, firm, etc.) DIET DIARY DAY 1

TIME FOOD / BEVERAGE / AMOUNT COMMENTS

Bowel Movements (#, form, color) Stress/Mood/Emotions

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DAY 2

TIME FOOD / BEVERAGE / AMOUNT COMMENTS

Bowel Movements (#, form, color) Stress/Mood/Emotions DAY 3

TIME FOOD / BEVERAGE / AMOUNT COMMENTS

Bowel Movements (#, form, color) Stress/Mood/Emotions

Please return this packet no later than 48 hours prior to your appointment.