Center for
Functional Medicine
Introductory
Patient Information
Cleveland Clinic – Main Campus
Desk H-18
9500 Euclid Avenue
Cleveland, OH 44195
Phone 216-445-6900
Fax 216-636-3074
Clevelandclinic.org/functionalmedicine
[email protected]
Dear Patient,
Welcome to the Cleveland Clinic Center for Functional Medicine. We look forward to meeting you.
WHAT TO EXPECT AT THE CLEVELAND CLINIC
CENTER FOR FUNCTIONAL MEDICINE
Please arrive 30 minutes before your appointment time
OFFICE-Check In
(30 minutes)
Welcome to the Center for Functional Medicine
Update personal i n f o r m a t i o n and sign consent
forms
Meet Nurse or MA for vital signs
MD CONSULTATION:
Mark Hyman, MD; Patrick Hanaway, MD; Dirk Parvus, MD; Melissa Young, MD
(75 minute appointment)
Medical Assessment a n d Initial Treatment Plan
LABS – REVIEW OF RECOMMENDED TESTING: RN
(30 minute appointment)
Review of lab orders, test description and test prices
LAB VISIT: G10 Lab
(60 minutes)
NUTRITIONIST CONSULTATION:
Trisha Howell, MSH, RD, LD/N, HHC, Brigid Titgemeier, MS, RDN, LD
(45 minute appointment)
Nutrition Assessment a n d Initial Nutrition Plan
HEALTH COACH - WRAP UP AND REVIEW
(15 minute appointment)
Exit plan and information review
Registration for Healthy Living Supplement Store
RECEPTION OFFICE-Check Out
(10 minutes)
Schedule follow-up appointment(s)
PRACTICE POLICIES FOR PATIENTS_____________________________________________________
Our goal at the Center for Functional Medicine is to provide you with the highest level of personalized care. We are committed
to helping you achieve optimal health.
It is important to read all the enclosed information carefully and mail or fax the medical questionnaire to our office at least 7
days prior to your appointment (address on next page). This will allow us to help solve your problems more efficiently and
enhance the quality of your care. If your patient packet is late, it may take up to 30 minutes of your appointment time to review
your records.
WEBSITE
Information about the Center for Functional Medicine is available through our website, clevelandclinic.org/functionalmedicine.
MEDICAL RECORDS
Medical records can only be released with your authorization. You are responsible for obtaining previous medical records from
other physicians or health care providers who are not affiliated with Cleveland Clinic. A medical records release form is
included for your use. Please contact your physician or other health care provider to obtain these records. Your records should
be express mailed to Cleveland Clinic – Center for Functional Medicine, 9500 Euclid Avenue – H-18, Cleveland, OH 44195.
If your care has been with Cleveland Clinic providers, your records are available to us through our electronic medical record.
You do not need to request a release for these records.
CONSULTATIONS
Your initial visit will include a 75-minute medical consultation with your physician and a 45-minute nutrition consultation.
Nutritional therapy and laboratory/diagnostic testing are integral components of your treatment plan. Test results are used to
design your personal health care program as well as uncover the root causes of your medical condition. Nutritional supplements
are often recommended and we will help you find and select the highest quality products.
INITIAL VISITS
Many of the tests require a 10-hour fast. You can, and should, drink water during this fast and take all prescription medication.
Costs of all testing will be reviewed with you by our staff after your medical consultation before labs are drawn.
You will receive all final lab results and be guided through their interpretation at your follow-up visits.
CONFIRMATION AND CANCELLATION OF APPOINTMENTS
If you must cancel or re-schedule your appointment, please contact us at least seven (7) days prior to your appointment. To
cancel or re-schedule your appointment, please contact our office at 216-445-6900.
INSURANCE INFORMATION
Physician visits are covered by most insurance plans. Coverage for visits with the nutritionist, as well as some of the tests, is
determined by your insurance plan. Our financial counselor will talk to you to review your coverage prior to your appointment
if necessary.
PAYMENT OPTIONS
If it is determined that services are not covered by insurance, our office accepts cash, checks or credit cards for services
rendered.
APPOINTMENTS WITH DR. HYMAN
*All appointments with Dr. Mark Hyman are self-pay. Appointments with Dr. Hyman are not billed through insurance. Dr.
Hyman does not accept insurance and we do not file insurance paperwork on your behalf. However, we will provide a detailed
receipt for services performed for you to submit to your insurance carriers.
Dr. Hyman does not participate in the Medicare program. If you are a Medicare Part B beneficiary and wish to become a
patient of Dr. Hyman, you are required to accept the terms and conditions set forth in a Private Contract between you and Dr.
Hyman. This Private Contract provides that absolutely no Medicare payment will be made to you or to the Cleveland Clinic for
the services provided, even if such services are covered by Medicare. Under the Private Contract, you acknowledge that you
accept full responsibility for the payment of charges for all services rendered by Dr. Hyman; such payments are due in full at the
time of service. This contract will be reviewed with you prior to your appointment. The Cleveland Clinic will not require you
to sign the Private Contract if you are experiencing an emergency or urgent issue.
HOW TO CONTACT US:
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Our office hours are Monday- Friday 8:00 am to 5:00 pm EST.
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To reach the Center for Functional Medicine office, please call 216-445-6900.
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Our fax number is 216-636-3074.
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Our email address is [email protected]
•
After your appointment, the best way to ask a question or leave a message for your doctor or nutritionist is
through MyChart. If you have not signed up for MyChart yet, we are able to assist you.
•
If you have a medical emergency, call 911 or go directly to the nearest emergency room.
ADDRESS:
Cleveland Clinic
Center for Functional Medicine
9500 Euclid Avenue, H-18
Cleveland, OH 44195
PRESCRIPTION REFILLS
It may take up to 5 business days to process a prescription refill. Please plan ahead to avoid any interruptions in your
medications. Prescription refills can be faxed to our office by your pharmacy. Our fax number is 216-636-3074.
You can also request a refill through MyChart.
DIRECTIONS TO CLEVELAND CLINIC CENTER FOR FUNCTIONAL MEDICINE
The Cleveland Clinic Center for Functional Medicine is located on the main campus of the Cleveland Clinic in the H building.
Parking is recommended in the Parking 1 Garage (E. 93rd Street) or Valet is available at the Main Entrance (E. 93rd Street).
For a map of main campus, visit ClevelandClinic.org
FREQUENTLY ASKED QUESTIONS_____________________________________________________
Will I see other practitioners at the Center for Functional Medicine?
Nutritional therapy is a vital component of your treatment plan. Following your initial medical consultation with a physician,
you will meet with one of our nutritionists who will provide recommendations based on your health concerns and tailor your diet
based on medical evaluation and test results. You will follow-up with a nutritionist to make changes or updates to your plan
based on your progress. In addition, you will be in contact with our Health Coach. The Health Coach will review your plan and
work with you to set both short-term and long-term goals towards improving your health. Your Health Coach will meet you at
your first visit and follow up with you by phone or email.
Do you take insurance?
Physician visits are covered by most insurance plans. Coverage for visits with the nutritionist as well as some of the lab tests is
determined by your insurance plan. You will talk to our financial counselor to review your coverage prior to your appointment
if there is a question regarding your coverage.
*Appointments with Dr. Mark Hyman are not billed through insurance. Dr. Hyman does not accept insurance or Medicare and
we do not file insurance paperwork on your behalf. However, we will provide a detailed receipt for services performed for you
to submit to your insurance carriers.
Are Center for Functional Medicine physicians primary care physicians?
The physicians are trained as primary care physicians but they do not provide acute care or primary care services. They will
work with you closely as consultants in preventive, nutritional and functional medicine to help you address the roots of chronic
health problems. They can confer with your primary care doctor.
Can all the tests I need be done at the Cleveland Clinic?
Most of the testing can be performed at the Cleveland Clinic (G-10 lab). During your medical consultation, your physician will
determine which tests are needed and then our nurses will review testing recommendations, instructions (for instance, fasting or
non-fasting, etc.) and costs, if applicable.
The plan for testing is reviewed with you. You are able to determine what testing to complete based on how much testing you
want to do and your out of pocket expense for labs. Testing is frequently done to assess nutritional status including amino acids,
fatty acids, oxidative stress, vitamin levels, mitochondrial function, food allergies, and heavy metals. Many additional tests are
available, including genetic testing for a variety of conditions, hormone evaluations, bone health, gastrointestinal health, adrenal
function and others.
Some testing can be performed at home with test kits to collect urine, saliva or stool. Our nurse will review the instructions for
completing these tests at home.
While the testing gives a more complete picture of your status, effective care can be implemented without it, or testing can be
done over time. You should not let this prevent you from seeing one of the doctors.
Center for Functional Medicine
Health
Questionnaires
Cleveland Clinic – Main Campus
Desk H-18
9500 Euclid Avenue
Cleveland, OH 44195
Phone 216-445-6900
Fax 216-636-3074
Clevelandclinic.org/functionalmedicine
[email protected]
GENERAL INFORMATION____________________________________________________________
Name
First
Middle
Last
☐ Male
☐ African
☐ Asian
☐ High School
☐ Female
☐ European
☐ Native American ☐ Mediterranean
☐ Ashkenazi
☐ Middle Eastern ☐ _______________
☐ Under-Graduate ☐ Post-Graduate
Preferred Name
Date of Birth
Age
Gender
Genetic Background
Highest Education Level
Job Title
Nature of Business
Primary Address
Number, Street
City
Alternate Address
State
Zip
State
Zip
Number, Street
City
Home Phone
Work Phone
Cell Phone
Fax
E-mail
Emergency Contact
Name
Phone Number
Cell Phone
Relationship
Primary Care Physician
Address
Work Number
City
State
Name
Phone Number
Zip
Fax
Referred by
☐ Book
☐PCP
☐ Website
☐ CC Physician
☐ Media
☐ Other
☐ Family or Friend
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ALLERGIES______________________________________________________________
Medication / Supplement / Food
Reaction
COMPLAINTS CONCERNS_________________________________________________
What do you hope to achieve in your visit with us?______________________________________________________________
_______________________________________________________________________________________________________
If you had a magic wand and could erase three problems, what would they be?
1.
_______________________________________________________________________________________________
2.
_______________________________________________________________________________________________
3.
________________________________________________________________________________________________
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? _______________________________________________________________________________
_______________________________________________________________________________________________________
X
Fair
Good
Prior Treatment/Approach
Elimination Diet
Excellent
Severe
Moderate
Describe Problem
Example: Post Nasal Drip
Mild
Please list current and ongoing problems in order of priority:
X
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MEDICAL HISTORY_____________________________________________________
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GASTROINTESTINAL
Irritable Bowel Syndrome_________________
Inflammatory Bowel Disease______________
Crohn’s_______________________________
Ulcerative Colitis_______________________
Gastritis or Peptic Ulcer Disease___________
GERD (reflux)__________________________
Celiac Disease__________________________
Other _________________________________
CARDIOVASCULAR
Heart Attack___________________________
Other Heart Disease_____________________
Stroke________________________________
Elevated Cholesterol_____________________
Arrhythmia (irregular heart rate)____________
Hypertension (high blood pressure)_________
Rheumatic Fever________________________
Mitral Valve Prolapse____________________
Other _________________________________
METABOLIC/ENDOCRINE
Type 1 Diabetes_________________________
Type 2 Diabetes_________________________
Hypoglycemia___________________________
Metabolic Syndrome_____________________
(Insulin Resistance or Pre-Diabetes)
Hypothyroidism (low thyroid)______________
Hyperthyroidism (overactive thyroid)________
Endocrine Problems______________________
Polycystic Ovarian Syndrome (POCS)_______
Infertility_______________________________
Weight Gain____________________________
Weight Loss____________________________
Frequent Weight Fluctuations______________
Bulimia________________________________
Anorexia_______________________________
Binge Eating Disorder____________________
Night Eating Syndrome___________________
Eating Disorder (non-specific)______________
Other _________________________________
CANCER
Lung Cancer____________________________
Breast Cancer___________________________
Colon Cancer___________________________
Ovarian Cancer_________________________
Prostate Cancer_________________________
Skin Cancer____________________________
Other _________________________________
Past
Condition
Ongoing
Condition
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Ongoing
Condition
Past
Condition
DISEASES/DIAGNOSIS/CONDITIONS Check appropriate box and provide date of onset
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GENITAL AND URINARY SYSTEM
Kidney Stones__________________________
Gout__________________________________
Interstitial Cystitis_______________________
Frequent Urinary Tract Infections___________
Frequent Yeast Infections_________________
Erectile Dysfunction_____________________
Or Sexual Dysfunction
Other ________________________________
MUSCULOSKELETAL/PAIN
Osteoarthritis___________________________
Fibromyalgia___________________________
Chronic Pain___________________________
Other _________________________________
INFLAMMATORY/AUTOIMMUNE
Chronic Fatigue Syndrome________________
Autoimmune Disease____________________
Rheumatoid Arthritis_____________________
Lupus SLE_____________________________
Immune Deficiency Disease_______________
Herpes-Genital_________________________
Severe Infectious Disease_________________
Poor Immune Function___________________
(frequent infections)
Food Allergies__________________________
Environmental Allergies__________________
Multiple Chemical Sensitivities____________
Latex Allergy__________________________
Other _______________________________
RESPIRATORY DISEASES
Asthma_______________________________
Chronic Sinusitis_______________________
Bronchitis_____________________________
Emphysema___________________________
Pneumonia____________________________
Tuberculosis___________________________
Sleep Apnea___________________________
Other ________________________________
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SKIN DISEASES
Eczema_______________________________
Psoriasis______________________________
Acne_________________________________
Melanoma_____________________________
Skin Cancer____________________________
Other ________________________________
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NEUROLOGICAL
Depression____________________________
Anxiety_______________________________
Bipolar Disorder_______________________
Schizophrenia__________________________
Headaches____________________________
Migraines_____________________________
ADD/ADHD__________________________
Autism_______________________________
PREVENTIVE TESTS AND
DATE OF LAST TEST
Check box if yes and provide date
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Full Physical Exam__________________________
Bone Density_______________________________
Colonoscopy_______________________________
Cardiac Stress Test__________________________
EBT Heart Scan____________________________
EKG_____________________________________
Hemoccult Test-stool test for blood_____________
MRI_____________________________________
CT Scan__________________________________
Upper Endoscopy___________________________
Upper GI Series____________________________
Ultrasound_________________________________
INJURIES
Back Injury
Head Injury
Neck Injury
Broken Bones
Other_____________________________________
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Condition
Ongoing
Condition
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Condition
Past
Condition
MEDICAL HISTORY (continued)_______________________________________________
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Mild Cognitive Impairment________________
Memory Problems_______________________
Parkinson’s Disease_____________________
Multiple Sclerosis_______________________
ALS__________________________________
Seizures_______________________________
Other Neurological Problems______________
SURGERIES
Check box if yes and provide date of surgery
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Appendectomy______________________________
Hysterectomy +/- Ovaries_____________________
Gall Bladder_______________________________
Hernia____________________________________
Tonsillectomy______________________________
Dental Surgery_____________________________
Joint Replacement – Knee/Hip_________________
Heart Surgery - Bypass Valve_________________
Angioplasty or Stent_________________________
Pacemaker_________________________________
Other_____________________________________
None
BLOOD TYPE:
A
AB
Rh+
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O
Unknown
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HOSPITALIZATION
None
Date
Reason
COMMENTS
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GYNECOLOGIC HISTORY (for women only)____________________________________
OBSTETRIC HISTORY Check box if yes and provide number of
☐ Pregnancies___________ ☐ Caesarean____________
☐ Vaginal Deliveries____________
☐ Miscarriage___________ ☐ Abortion_____________
☐ Living Children______________
☐ Post-Partum Depression
☐ Toxemia ☐ Gestational Diabetes ☐ Baby Over 8 Pounds
☐ Breast Feeding for how long?____________
MENSTRUAL HISTORY
Age at First Period:______ Menses Frequency:_____ Length:_____ Pain:
☐Yes ☐No
Clotting:
☐Yes ☐No
Has you period ever skipped? _____ For how long?___________
Last Menstrual Period:____________
☐ Birth Control Pills ☐ Patch ☐ Nuva Ring How long?____________
☐No ☐ Condom ☐ Diaphragm ☐ IUD ☐ Partner Vasectomy
Use of hormonal contraception such as:
Do you use contraception?
☐Yes
WOMEN’S DISORDERS/HORMONAL IMBALANCES
☐ Fibrocystic Breasts ☐ Endometriosis ☐ Fibroids ☐ Infertility
☐ Painful Periods ☐ Heavy Periods ☐ PMS
Last Mammogram:______________ ☐ Breast Biopsy/Date:_____________
Last PAP Test:______________ ☐ Normal ☐ Abnormal
Last Bone Density:______________ Results: ☐High ☐Low ☐Within Normal Range
Are you in Menopause? ☐Yes ☐No
Age at Menopause:____________
☐Hot Flashes ☐Mood Swings ☐Concentration/Memory Problems ☐Vaginal Dryness ☐Decreased Libido
☐Heavy Bleeding ☐Joint Pains ☐Headaches ☐Weight Gain ☐Loss of Control of Urine ☐Palpitations
☐Use of hormone replacement therapy How long?______________________
MEN’S HISTORY (for men only)_______________________________________________
☐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
Have you had a PSA done?
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GI HISTORY_____________________________________________________________
☐Yes ☐ No Where?___________________________________________________________________
Wilderness Camping ☐Yes ☐ No Where?______________________________________________________________
Have you ever had severe: ☐ Gastroenteritis ☐ Diarrhea
Do you feel like you digest your food well? ☐Yes ☐ No
Do you feel bloated after meals? ☐Yes ☐ No
Foreign Travel
PATIENT BIRTH HISTORY________________________________________________
☐ Term ☐ Premature
Pregnancy Complications:__________________________________________________________________________________
Birth Complications:______________________________________________________________________________________
☐ Breast Fed
How long?______________
☐ Bottle Fed
Age at introduction of: Solid Foods:____________
Did you eat a lot of candy or sugar as a child?
Dairy:____________
☐Yes ☐ No
Wheat:____________
DENTAL HISTORY_______________________________________________________
☐ Silver Mercury Fillings How many?____________
☐ Gold Fillings ☐ Root Canals ☐ Implants ☐ Tooth Pain ☐ Bleeding Gums
☐ Gingivitis ☐ Problems with Chewing
Do you floss regularly? ☐Yes ☐ No
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MEDICATIONS___________________________________________________________
CURRENT MEDICATIONS
Medication
Dose
Frequency
Start Date (month/year)
Reason For Use
Start Date (month/year)
Reason For Use
PREVIOUS MEDICATIONS (Last 10 years)
Medication
Dose
Frequency
NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY)
Supplement & Brand
Dose
Frequency
Start Date (month/year)
Have your medications or supplements ever caused you unusual side effects or problems?
Reason For Use
☐Yes ☐ No
Describe:_____________________________________________________________________________________________
Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin?
Have you had prolonged use of Tylenol?
☐Yes ☐ No
☐Yes ☐ No
Have you had prolonged or regular use of acid blocking drugs (Tagamet, Zantac, Prilosec, etc.)
☐Yes ☐ No
Long term antibiotics ☐Yes ☐ No
☐Yes ☐ No
Frequent antibiotics
Use of steroids (prednisone, nasal allergy inhalers) in the past
Use of oral contraceptives
☐Yes ☐ No
☐Yes ☐ No
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Other
Uncle
Aunt
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Children
Sister(s)
Brother(s)
Father
Mother
Check family members that apply
Maternal Grandmother
FAMILY HISTORY_______________________________________________________
Age (if still alive)
Age at death (if deceased)
Cancers
Colon Cancer
Breast or Ovarian Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing Spondylitis)
Inflammatory Bowel Disease
Multiple Sclerosis
Auto Immune Diseases (such as Lupus)
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema / Psoriasis
Food Allergies, Sensitivities or Intolerances
Environmental Sensitivities
Dementia
Parkinson’s
ALS or other Motor Neuron Diseases
Genetic Disorders
Substance Abuse (such as alcoholism)
Psychiatric Disorders
Depression
Schizophrenia
ADHD
Autism
Bipolar Disease
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SOCIAL HISTORY________________________________________________________
NUTRITION HISTORY
Have you ever had a nutrition consultation?
☐Yes ☐ No
Have you made any changes in your eating habits because of your health?
Do you currently follow a special diet or nutritional program?
☐Yes ☐ No Describe:_____________________
☐Yes ☐ No
Check all that apply:
☐ Low Fat ☐ Low Carbohydrate ☐ High Protein ☐ Low Sodium ☐ Diabetic ☐ No Dairy ☐ No Wheat
☐ Gluten Restricted ☐ Vegetarian ☐ Vegan ☐ Ultrametabolism
☐ Specific Program for Weight Loss/Maintenance Type:_______________________ ☐ Other_________________________
Height (feet/inches)_______________________________
Current Weight___________________________________
Usual Weight Range +/- 5 lbs_______________________
Desired Weight Range +/- 5 lbs______________________
Highest Adult Weight_____________________________
Lowest Adult Weight______________________________
☐Yes ☐ No
Body Fat %______________________________________
How often do you weigh yourself? ☐ Daily ☐ Weekly ☐ Monthly ☐ Rarely ☐ Never
Have you ever had your metabolism (resting metabolic rate) checked? ☐Yes ☐ No If yes, what was it?________________
Do you avoid any particular foods? ☐Yes ☐ No If yes, types and reason_________________________________________
Weight Fluctuations (>10 lbs)
_______________________________________________________________________________________________________
If you could only eat a few foods a week, what would they be?_____________________________________________________
_______________________________________________________________________________________________________
☐Yes ☐ No If no, who does the shopping?______________________________________________
Do you read food labels? ☐Yes ☐ No
Do you cook? ☐Yes ☐ No If no, who does the cooking?_____________________________________________________
How many meals to you eat out per week? ☐ 0-1 ☐ 1-3 ☐ 3-5 ☐ > 5 meals per week
Do you grocery shop?
Check all the factors that apply to your current lifestyle and eating habits:
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Fast eater
Erratic eating pattern
Eat too much
Late night eating
Dislike healthy food
Time constraints
Eat more than 50% meals away from home
Travel frequently
Non-availability of healthy foods
Do not plan meals or menus
Reliance on convenience items
Poor snack choices
Significant other or family members don’t like healthy
foods
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Significant other or family members have special
dietary needs or food preferences
Love to eat
Eat because I have to
Have a negative relationship to food
Struggle with eating issues
Emotional eater (eat when sad, lonely, depressed,
bored)
Eat too much under stress
Eat too little under stress
Don’t care to cook
Eating in the middle of the night
Confused about nutrition advice
The most important thing I should change about my diet to improve my health is:______________________________________
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SMOKING
Currently Smoking?
☐Yes ☐ No
If yes, how many years?_________ Packs per day:_________
Attempts to quit:____________
Previous Smoking: How many years?____________ Packs per day:____________
Second Hand Smoke Exposure?_________________
ALCOHOL INTAKE
How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits
☐ None ☐ 1-3 ☐ 4-6 ☐ 7-10 ☐ > 10 If none, skip to “Other Substances”
Previous alcohol intake? ☐ Yes (☐ Mild ☐ Moderate ☐High) ☐ None
Have you ever been told you should cut down your alcohol intake? ☐Yes ☐ No
Do you get annoyed when people ask you about your drinking? ☐Yes ☐ No
Do you ever feel guilty about your alcohol consumption? ☐Yes ☐ No
Do you ever take an eye-opener? ☐Yes ☐ No
Do you notice a tolerance to alcohol (can you ”hold” more than others)? ☐Yes ☐ No
Have you ever been unable to remember what you did during a drinking episode? ☐Yes ☐ No
Do you get into arguments or physical fights when you have been drinking? ☐Yes ☐ No
Have you ever thought about getting help to control or stop your drinking? ☐Yes ☐ No
OTHER SUBSTANCES
Caffeine Intake: ☐Yes ☐ No | Coffee cups/day: ☐ 1 ☐ 2-4 ☐ > 4 | Tea cups/day: ☐ 1 ☐ 2-4 ☐ > 4
Caffeinated Sodas or Diet Sodas Intake: ☐Yes ☐ No
12-ounce can/bottle: ☐ 1 ☐ 2-4 ☐ > 4
List favorite type (Ex. Diet Coke, Pepsi, etc.): __________________________________
☐Yes ☐ No If yes, type:___________________________
Have you ever used IV or inhaled recreational drugs? ☐Yes ☐ No
Are you currently using any recreational drugs?
EXERCISE
Current Exercise Program: (List type of activity, number of sessions/week, and duration)
Activity
Type
Frequency Per Week
Duration in Minutes
Stretching
Cardio/Aerobics
Strength
Other (yoga, pilates, gyrotonics, etc.)
Sports or Leisure Activities
(golf, tennis, rollerblading, etc.)
Rate your level of motivation for including exercise in your life?
☐ Low ☐ Medium ☐ High
List problems that limit activity:_____________________________________________________________________________
_______________________________________________________________________________________________________
Do you feel unusually fatigued after exercise?
☐Yes ☐ No
If yes, please describe:_____________________________________________________________________________________
_______________________________________________________________________________________________________
Do you usually sweat when exercising?
☐Yes ☐ No
10
PSYCHOSOCIAL
Do you feel significantly less vital than you did a year ago?
Are you happy?
☐Yes ☐ No
Do you feel your life has meaning and purpose?
☐Yes ☐ No
☐Yes ☐ No
Do you believe stress is presently reducing the quality of your life?
Do you like the work you do?
☐Yes ☐ No
Have you ever experienced major losses in your life?
☐Yes ☐ No
☐Yes ☐ No
Do you spend the majority of your time and money to fulfill responsibilities and obligations?
Would you describe your experience as a child in your family as happy and secure?
☐Yes
☐Yes ☐ No
☐ No
STRESS/COPING
Have you ever sought counseling?
☐Yes ☐ No
Are you currently in therapy? ☐Yes ☐ No Describe:________________________________________________________
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 on scale of 1-10
Work_____ Family_____ Social_____ Finances_____ Health_____ Other_____
☐Yes ☐ No How often?____________
Check all that apply: ☐ Yoga ☐ Meditation ☐ Imagery ☐ Breathing ☐ Tai Chi ☐ Prayer ☐ Other:_______________
Have you ever been abused, a victim of a crime, or experienced a significant trauma? ☐Yes ☐ No
SLEEP/REST
Average number of hours you sleep per night: ☐ > 10 ☐ 8-10 ☐ 6-8 ☐ < 6
Do you have trouble falling asleep? ☐Yes ☐ No
Do you feel rested upon awakening? ☐Yes ☐ No
Do you have problems with insomnia? ☐Yes ☐ No
Do you snore? ☐Yes ☐ No
Do you use sleeping aids? ☐Yes ☐ No Explain:____________________________________________________________
ROLES/RELATIONSHIP
Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Long term partnership ☐ Widow
Do you practice meditation or relaxation techniques?
List Children: Child’s Full Name
Age
Gender
Who is Living in Household? Number:________ Names:_______________________________________________________
Their Employement/Occupations:____________________________________________________________________________
Resources for emotional support?
☐ Spouse ☐ Family ☐ Friends ☐ Religious/Spiritual ☐ Pets ☐ Other:_____________________
Are you satisfied with your sex life? ☐Yes ☐ No
Check all that apply:
11
How well have things been going for you?
-
Overall
-
At school
-
In your job
-
In your social life
-
With close friends
-
With sex
-
With your attitude
-
With your boyfriend/girlfriend
-
With your children
-
With your parents
-
With your spouse
Very Well
Fine
Poorly
N/A
ENVIRONMENTAL AND DETOXIFICATION ASSESSMENT__________________
Do you have known adverse food reactions or sensitivities?
☐Yes ☐ No
If yes, describe symptoms:
_______________________________________________________________________________________________________
☐Yes List all:________________________________________ ☐ No
Do you have an adverse reaction to caffeine? ☐Yes ☐ No
When you drink caffeine do you feel: ☐ Irritable or Wired ☐ Aches and Pains
Do you have any food allergies or sensitivities?
Do you adversely react to (Check all that apply)
☐ Monosodium glutamate (MSG) ☐ Aspartame (NutraSweet) ☐ Caffeine ☐ Bananas ☐ Garlic ☐ Onion
☐ Cheese ☐ Citrus Foods ☐ Chocolate ☐ Alcohol ☐ Red Wine
☐ Sulfite Containing Foods (wine, dried fruit, salad bars) ☐ Preservatives (ex. Sodium Benzoate)
☐ Other:_______________________________________________________________________________________________
Which of these significantly affect you? (Check all that apply)
☐ Cigarette Smoke ☐ Perfumes/Colognes ☐ Auto Exhaust Fumes ☐ Other:_____________________________________
In your work or home environment, are you exposed to: ☐ Chemicals ☐ Electromagnetic Radiation ☐ Mold
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, Date, 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 exposure?
Do you have pets or farm animals?
☐Yes ☐ No
☐Yes ☐ No
12
SYMPTOM REVIEW__________________________________________________________________
Please check all current symptoms occurring or present in the past 6 months
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GENERAL
Cold Hands & Feet
Cold Intolerance
Low Body Temperature
Low Blood Pressure
Daytime Sleepiness
Difficulty Falling Asleep
Early Waking
Fatigue
Fever
Flushing
Heat Intolerance
Night Waking
Nightmares
No Dream Recall
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HEAD, EYES & EARS
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MUSCULOSKELETAL
Conjunctivitis
Distorted Sense of Smell
Distorted Taste
Ear Fullness
Ear Pain
Ear Ringing/Buzzing
Lid Margin Redness
Eye Crusting
Eye Pain
Hearing Loss
Hearing Problems
Headache
Migraine
Sensitivity to Loud Noises
Vision Problems (other than glasses)
Macular Degeneration
Vitreous Detachment
Retinal Detachment
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 – Arms or Legs
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Muscle Weakness
Tendonitis
Tension Headache
TMJ Problems
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MOOD/NERVES
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Difficulty
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EATING
Agoraphobia
Anxiety
Auditory Hallucinations
Black-out
Depression
Concentrating
With Balance
With Thinking
With Judgment
With Speech
With Memory
Dizziness (Spinning)
Fainting
Fearfulness
Irritability
Light-headedness
Numbness
Other Phobias
Panic Attacks
Paranoia
Seizures
Suicidal Thoughts
Tingling
Tremor/Trembling
Visual Hallucinations
Binge Eating
Bulimia
Can’t Gain Weight
Can’t Lose Weight
Can’t Maintain Healthy Weight
Frequent Dieting
Poor Appetite
Salt Cravings
Carbohydrate Craving (breads, pasta)
Sweet Cravings (candy, cookies, cakes)
Chocolate Cravings
Caffeine Dependency
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DIGESTION
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Constipation
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Anal Spasms
Bad Teeth
Bleeding Gums
Bloating of Lower Abdomen
Bloating of Whole Abdomen
Bloating After Meals
Blood in Stools
Burping
Canker Sores
Cold Sores
Constipation
Cracking at Corner of Lips
Cramps
Dentures w/ Poor Chewing
Diarrhea
Alternating Diarrhea and
Difficulty Swallowing
Dry Mouth
Excess Flatulence/Gas
Fissures
Food “Repeat” (Reflux)
Gas
Heartburn
Hemorrhoids
Indigestion
Nausea
Upper Abdominal Pain
Vomiting
Intolerance to:
Lactose
All Dairy Products
Wheat
Gluten (Wheat, Rye, Barley)
Corn
Eggs
Fatty Foods
Yeast
Liver Disease/Jaundice
(yellow eyes/ skin)
Abnormal Liver Function Tests
Lower Abdominal Pain
Mucus in Stools
Periodontal Disease
Sore Tongue
Strong Stool Odor
Undigested Food in Stools
13
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SKIN PROBLEMS
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
Lack of Sweating
Eczema
Hives
Jock Itch
Lackluster Skin
Moles w/Color/Size Change
Oily Skin
Pale Skin
Patchy Dullness
Rash
Red Face
Sensitivity to Bites
Sensitivity to Poison Ivy/Oak
Shingles
Skin Darkening
Strong Body Odor
Hair Loss
Vitiligo
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ITCHING SKIN
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SKIN, DRYNESS OF
Skin in General
Anus
Arms
Ear Canals
Eyes
Feet
Hands
Legs
Nipples
Nose
Penis
Roof of Mouth
Scalp
Throat
Eyes
Feet
Any Cracking?
Any Peeling?
Hair
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Hair Unmanageable?
Hands
Any Cracking?
Any Peeling?
Mouth/Throat
Scalp
Any Dandruff?
Skin in General
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LYMPH NODES
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NAILS
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RESPIRATORY
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Hay Fever
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Enlarged/neck
Tender/neck
Other Enlarged/Tender
Lymph Nodes
Bitten
Brittle
Curve Up
Frayed
Fungus-Fingers
Fungus-Toes
Pitting
Ragged Cuticles
Ridges
Soft
Thickening of fingernails
Thickening of toenails
White Spots/Lines
Bad Breath
Bad Odor in Nose
Cough-Dry
Cough-Productive
Hoarseness
Sore Throat
Spring
Summer
Fall
Change of Season
Nasal Stuffiness
Nose Bleeds
Post Nasal Drip
Sinus Fullness
Sinus Infection
Snoring
Wheezing
Winter Stuffiness
CARDIOVASCULAR
Angina/chest pain
Breathlessness
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Heart Murmur
Irregular Pulse
Palpitations
Phlebitis
Swollen Ankles/Feet
Varicose Veins
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URINARY
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MALE REPRODUCTIVE
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FEMALE REPRODUCTIVE
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Premenstrual:
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Menstrual:
Bed Wetting
Hesitancy (trouble getting started)
Infection
Kidney Disease
Leaking/Incontinence
Pain/Burning
Prostate Infection
Urgency
Discharge From Penis
Ejaculation Problem
Genital Pain
Impotence
Prostate or Urinary Infection
Lumps in Testicles
Poor Libido (Sex Drive)
Breast Cysts
Breast Lumps
Breast Tenderness
Ovarian Cyst
Poor Libido (Sex Drive)
Vaginal Discharge
Vaginal Odor
Vaginal Itch
Vaginal Pain with Sex
Bloating Breast Tenderness
Carbohydrate Cravings
Chocolate Cravings
Constipation
Decreased Sleep
Diarrhea
Fatigue
Increased Sleep
Irritability
Cramps
Heavy Periods
Irregular Periods
No Periods
Scanty Periods
Spotting Between
14
READINESS ASSESSMENT________________________________________________
Rate on a scale of 5 (very willing) to 1 (not willing):
In order to improve your health, how willing are you to:
☐5
Take several nutrition supplements each day…………………………☐5
Keep a record of everything you eat each day……………………… ☐5
Modify your lifestyle (e.g., work demands, sleep habits)……………☐5
Practice a relaxation technique……………………………………….☐5
Engage in regular exercise……………………………………………☐5
Have periodic lab tests to assess your progress………………………☐5
Significantly modify your diet……………………………………….
☐4 ☐ 3 ☐ 2
☐4 ☐3 ☐2
☐4 ☐ 3 ☐ 2
☐4 ☐3 ☐2
☐4 ☐3 ☐2
☐4 ☐3 ☐2
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☐1
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☐1
Comments______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Rate on a scale of 5 (very confident) to 1 (not confident at all):
How confident are your of your ability to organize and follow through on the above health related activities?
☐ 5 ☐4 ☐ 3 ☐ 2 ☐1
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in
the above activities?______________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Rate on a scale of 5 (very supportive) to 1 (very unsupportive):
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
☐ 5 ☐4 ☐ 3 ☐ 2 ☐1
Comments______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):
How much on-going support and contact (e.g., telephone consults, e-mail correspondence) from our professional staff would be helpful to you
as you implement your personal health program?
☐ 5 ☐ 4 ☐3 ☐ 2 ☐1
Comments______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
15
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.
• 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 ½ and ½).
• 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 sweet, skipped meal 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_____________________________________________________
Name:____________________________________________________ Date:_______________________________________
Daily Exercise (Type of Activity / Time of Day / Duration): ______________________________________________________
_______________________________________________________________________________________________________
Daily Bowel Movements:__________________________________________________________________________________
TIME
FOOD/ BEVERAGE / AMOUNT
COMMENTS
16
DIET DIARY – DAY 2_____________________________________________________
Name:____________________________________________________ Date:_______________________________________
Daily Exercise (Type of Activity / Time of Day / Duration): ______________________________________________________
_______________________________________________________________________________________________________
Daily Bowel Movements:__________________________________________________________________________________
TIME
FOOD/ BEVERAGE / AMOUNT
COMMENTS
DIET DIARY – DAY 3_____________________________________________________
Name:____________________________________________________ Date:_______________________________________
Daily Exercise (Type of Activity / Time of Day / Duration): ______________________________________________________
_______________________________________________________________________________________________________
Daily Bowel Movements:__________________________________________________________________________________
TIME
FOOD/ BEVERAGE / AMOUNT
COMMENTS
17
OTHER COMMENTS / QUESTIONS/ CONCERNS:___________________________
18
Medical Symptoms Questionnaire
Name ____________________________________
Date _________________
Rate each of the following symptoms based upon your typical health profile for the past 30 days
Point Scale
0
1
2
3
4
HEAD
________
________
________
________
Headaches
Faintness
Dizziness
Insomnia
Total ________
________
________
________
________
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
(does not include near or far-sightedness)
Total ________
________
________
________
________
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total ________
________
________
________
________
________
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total ________
________
________
________
________
________
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total ________
________
________
________
________
________
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Total ________
________
________
________
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total ________
EYES
EARS
NOSE
MOUTH/THROAT
SKIN
HEART
-
Never or almost never have the symptom
Occasionally have it, effect is not severe
Occasionally have it, effect is severe
Frequently have it, effect is not severe
Frequently have it, effect is severe
19
LUNGS
DIGESTIVE TRACT
JOINTS/MUSCLE
WEIGHT
ENERGY/ACTIVITY
MIND
EMOTIONS
OTHER
________
________
________
________
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total ________
________
________
________
________
________
________
________
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total ________
________
________
________
________
________
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total ________
________
________
________
________
________
________
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Total ________
________
________
________
________
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total ________
________
________
________
________
________
________
________
________
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total ________
________
________
________
________
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total ________
________
________
________
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total ________
GRAND TOTAL
TOTAL _________
20