Name
Name
Name *
Name
Phone *
Phone
Personal medical history *
Please list past medical conditions and hospitalizations
Family history *
Please list medical conditions in the family including: siblings, parents, and grandparents.
Allergies
Please list all allergies past and present
Smoking and Recreational drugs *
Never
Quit within the past year
Quit more than a year ago
Yes
Medications and supplements *
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
Symptoms (other)
Please list any other symptoms or health concerns not listed above that you have currently experienced whether they seem related or not to your present chief health concern(s).
Bowel movements *
1 - 2 times/d
3 - 4 times/d
Every other day
Only a few times a day
Other
Description of flow
Description of menstrual flow (color, volume, etc)
Meal times *
My typical times for breakfast, lunch, and dinner are?
Include snack times
I eat fruit *
Every meal
At least one meal
Only as a snack
A few times a week
Once a week
Rarely
I eat vegetables *
Every meal
At least one meal
Only as a snack
A few times a week
Once a week
Rarely
My grains are *
Refined (White bread, white rice)
Whole grain (Brown bread, brown rice)
Mixed
Enriched
I don't eat grains
I eat grains *
Every meal
Only about once a day
A few times a week
Once a week
Rarely
I don't eat grains
I enjoy fried foods *
Almost daily
A few times a week
Rarely
I eat nuts *
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat beans
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat meat *
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat dairy products *
Almost every meal
Daily
A few times a week
Once a week
Rarely
Snack foods I enjoy are
I eat out *
About once a day
Few times a week
Once a week
Rarely
I drink water *
Throughout day
A little throughout the day
I don't drink much water
Cups of coffee per day *
3+
1 - 2
Rarely
Never
Cups of tea per day *
3+
1 - 2
Rarely
Never
I drink juices *
Almost every meal
Daily
A few times a week
About once a week
Rarely or never
I drink fluids with my meals *
Yes
No
I drink alcohol *
Daily
A few times a week
Only weekends
Only social occasions
None
Frequency of physical activity *
How many days a week are you doing structured physical activity?
Current physical activities *
Please share with us what types of exercise activities you are currently engaged in
Activity preferences
Please list any activities you would like to explore and also activities you absolutely dislike doing.
Gym membership
Have membership
No - not interested
No - interested
No - interested but financially difficult
Barriers to physical activity
List if any
Direct sunlight each day? *
I'm out in the sun often
Rarely
Typical hours of sleep each night *
I feel well rested after sleeping *
Generally yes
Generally no
It varies
Bed time and wake time *
When do you typically go to bed and when do you usually wake up?
Time to fall asleep *
Almost immediately
Up to 15 mins
Up to 30 mins
Up to an hour
Beyond 2 hours
Wake up in the middle of the night? *
Yes to use bathroom
Yes for no particular reason
Yes due to nightmares
Rarely
Other
Would you like to be added to our emailing list for clinic updates, promotions, and health information?
Yes
No
Comments
Please indicate any other comments you feel are necessary for us when considering your case
