2069N.BarringtonRd.
HoffmanEstates,IL60169
224.653.9878
PatientInformation
PatientName:
DateofBirth:
PhoneNumber:(
)
Email:
Address:
Occupation:
MaritalStatus: single
-
1.
2.
3.
4.
married
divorced
widowed
Listyourfivemajorhealthconcernsinorderof
importance
Listanyprescribed&OTCmedicationscurrentlytaking
Unknown
None
5.
Listanysupplements,vitamins,botanicals,or
homeopathicscurrentlytaking
Unknown
None
Anyknownmedicalconditions
Unknown
None
Importantpastmedicalconditions(ex.
surgeries/injuries)pleaseindicatewhen
WellnessSpecialist:
Datereviewed:
Allergies/Sensitivities/Intolerances
Unknown
None
Least
StressLevels
Scalefrom1-10
Most
1
2069N.BarringtonRd.
HoffmanEstates,IL60169
224.653.9878
BLOODSUGAR
Haveyoubeentoldbyadoctorthatyouareinsulinresistant,pre-diabetic,ordiabetic?..............................................
yes
no
yes
no
yes
no
yes
no
no………………...IFYES,aretheyrelievedbycaffeineorfood?
yes
no
Areyoumorethan20poundsyouridealbodyweight?.................................................................................................
yes
no
yes
no
yes
no
yes
no
THYROID
Doyoufeelexhaustedandtiredfrommorningtonight?.............................................................................................
yes
no
Doyouhavetroublewakingupinthemorning?…………….............................................................................................
yes
no
yes
no
yes
no
yes
no
courseordry.................................................................................................................………….
no
Doyoufeelirritableifamealismissedorgetheadaches,feelanxious/nervous/shakyifyougomorethan4hours
withouteating?................................................................................................................................................................
Cravesweetsorcoffeeinafternoonormid-morning………………………………………………………………………….…………….……….
Doyoucravecarbohydrates(breads,pasta,crackers)?.................................................................................................
Doyougetenergycrashesduringtheday?
yes
Doyouhavenightsweats?.............................................................................................................................................
Isyourmemory,concentration,orfocuspoor?.............................................................................................................
Doyougettiredaftereatingabigmeal?........................................................................................................................
Anyotherissuesconcerningyourbloodsugar?
Doyouhavedryskin,brittlehair/nails?........................................................................................................................
Doyouhavecoldhands/feet?.......................................................................................................................................
Areyoureyebrowsthinning(especiallyaroundtheedges)?.........................................................................................
Isyourhair
thinningOR
Doyouhaveahistoryofheartpalpitations?
yes
no………………….……IfYES,
AbnormallyrapidOR
Irregularheartbeat
Doyourhandsshakeortremble?.................................................................................................................................
yes
no
gainingweight?...............................................................................................………….
no
Doyouhavedifficulty
losingOR
Doyouhavehighenergylevels,followedbyexhaustionorextremetiredness?..........................................................
yes
no
Anyotherissuesconcerningthethyroid?
WellnessSpecialist:
Datereviewed:
2
STOMACH
Haveyouevertakenantibioticsforlongperiodsoftime(morethanaweekatatime)?.............................................
IFYES,howlongago
yes
no
eczema?...………………………..........................................................................
no
GERD(acidreflux)?..........................................................................................
no
Haveyouhadordoyouget
skinrashesOR
Haveyoubeendiagnosedwith
ulcerOR
Doyougetgassyorbloatedeasily,especiallyaftereatingameal?...............................................................................
yes
no
yes
no
yes
no
gobackandforthbetweenthetwo?......................................
no
Doyoufeelfullforextendedperiodsoftimeaftereating?...........................................................................................
Doyouhavestomachpainsbeforeoraftereating?.………………………….………………………………………………………………….…..
IFYES,doesitgetworsewithstressoremotionalupset? yes no
Doyouhavefrequent
constipationOR
diarrheaOR
Areyourbowelmovementspainfulordifficulttopass?…………………………………………………………………………….………….…..
yes
no
undigestedfoodsinyourstools………………………………….……………………………………….……………..
no
Istherevisible
bloodOR
Anyotherissuesconcerningthestomach?
CARDIOVASCULAR
Haveyoubeentoldyouhave
highbloodpressureOR
highcholesterol?...............……..………………………………………………
no
Doyouexerciseregularly?…………………………………………………...................................................……………….........……….…..
yes
no
yes
no
yes
no
Atrest?….........…………………………….…………………………
no
Doyoufeeloutofbreathafterwalkingupaflightofstairs?.....................................................………………......……….…..
Doyouhaveswellinginyourfeetand/orankles?…..…………......................................................………………......……….…..
Doyouexperienceany
chestpain?
Duringphysicalactivity?
Doyouhavedifficultybreathingatnight?………………………….........................................................………………...……….…..
yes
no
yes
no
faint?….........………………………….……………………………………………………………………
no
Doyourcalfmusclescrampwhilewalkingordoyouexperiencerestlesslegsyndromeatnight?.……………………….…..
Doyouget
light-headedeasilyAND/OR
Anyotherissuesconcerningcardiovascularhealth?
ADRENALS
Areyoueasilyirritated?..………………………………………………………………………………………….……...............................……….…..
yes
no
Inaday,howmuchcoffeedoyoudrink?
Tea?
……………………………………………………………………………………………
none
Doyourecoverpoorlyfrominjuryorillness?….…………………………………………….………………...............................……….…..
yes
no
yes
no
yes
no
Hasyourabilityorwanttoexercisedecreased?………………………………………………………………..............................……….…..
Doyouhaveenoughenergytogetyouthroughtheday?……………………………..…………....................................……….…..
Anythingelseyouwanttotellusaboutyourenergylevels?
WellnessSpecialist:
Datereviewed:
3
LUNGS
Doyouhave
difficultybreathingAND/OR
shortnessofbreath?…………………………………………………………………..……………
no
Doyougetchestpainwithdeepbreaths?……………………….......................................................……………….......……….…….
yes
no
yes
no
asthma?.……………………………………………………………….………………………..……………
no
Isthererattlinginyourlungswhenyoubreathe?.…..…………..............................................…………...................……….…..
Doyouhaveahistoryof
bronchitisOR
Doyou
smokeAND/OR
livearoundpeoplethatsmoke?.……………………………………………………………………………..……………
Haveyoueverbeenexposedtoasbestos?….……………………………………………………………………….…………….…….
yes
no
no
unsure
Doyouliveinanindustrializedareawithalargeamountofpollution?.…………...............................................……….…..
yes
no
yes
no
Anyotherissuesconcerninglunghealth?
SLEEP
Howmanyhoursanightofsleepdoyouget?
Areyouarestlesssleeperandawakenduringthenight?………………………………….……………..............................……….…..
Doyouhavedifficultyfallingasleep? yes
IFneither,pleaseexplain
no…………..IFYES,isitdueto
anxietyOR
replayingeventsoverandover?
Whenyouwakeupinthemorning,doyoufeelenergizedandreadyfortheday?…………………….…...............……….…..
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
Arethewhitesofyoureyesyellowed?.……………..……………………………………………...............................................……….…..
yes
no
Doyouhaveasourtasteinyourmouthoften?.………………………………………………..............................................……….…..
yes
no
yes
no
yes
no
Doyousnoretothepointthatotherpeoplecomment?…………....................................................………………..……….…..
Doyouhaveahistoryofsleepapnea?……………………………………………………………..........................………………....……….…..
Doyouhavenightmares?……………………………….………………………………………………...............………………...............……….…..
Doyouhavenightsweats?………………………………..…………………………………………….................……………...............……….…..
Anyotherissuesconcerningsleepinghabits?
LIVER
Areyouintolerantofgreasyfoods(ex.friedfoodsorfattymeats)?………………................................................……….…..
Doyouhavepainordiscomfortonyourrightsideunderyourribcage?.………................................................……….…..
Doyouhavealightcoloredoryellowishstool?................................................................................................……….…..
Doyouhavebadbreath?...………………………………..……………………………………………..............................................……….…..
Doyouhaveexcessivebodyodor?..…………………..…………………………………………….............................................……….…..
Howmuchalcoholdoyouconsumeinaweek?Pleaseexplain
WellnessSpecialist:
Datereviewed:
4
GENITOURINARY
Doyouhavepainorburningwhenurinating?.…………………………………………..……..............................................……….…..
yes
no
yes
no
yes
no
yes
no
Doyouhavefrequenturinationnotrelatedtotheamountofliquidsconsumed?.....…………………………………………..…..
Doyouhavecloudyurine?……………...................................................................................................................……….…..
Doyouhavedifficultyholdingyoururine?.………………………………………………………….………….............................………...…..
Haveyouhadahistoryof
urinarytractinfectionsAND/OR
Anyotherconcernsorissueswiththekidneys?
FEMALEQUESTIONSONLY
Itching………………………………….……….…..…… yes
cystitis?................………………………………….………..……………
no
no
Painfulintercourse……………………..…………..
yes
no
yes
no
yes
no
yes
no
Discharge…………………………..…………….…….
yes
no
Tenderbreasts……………………….………….…..
Vaginaldryness……………….…………….………
yes
no
Recurringyeastinfections..…….……….……..
Sexualdysfunction…………..………………..…..
yes
no
Diagnosedwithuterinefibroids……………..
RegularOR
IrregularmenstrualcyclesOR
Post-menopausal?
IFNOTPOST-MENOPAUSAL,doyouexperiencePMSsymptoms
IFYES,pleasedescribe
yes
no
MALEQUESTIONSONLY
Hesitancy…………………………….….………………
yes
no
Testicularmass…………..…………………….…………….
yes
no
Dribbling……………………………….……..…………
yes
no
Peniledischarge…………………………….……..………..
yes
no
yes
no
yes
no
yes
no
Decreasedstream…………………………………..
yes
no
Decreasedlibido……………………….……………….…..
Testicularpain…………………….…..……………..
yes
no
Erectiledysfunction……………….……………………….
Painfulintercourse……..………………………………….
Lastly,pleaseindicatetypicalfoodseateninanormal24hoursperiod,includinganysnacksandbeverages.
Breakfast:
Snack:
Lunch:
Snack:
Dinner:
Snack:
Howmanyglassesofwaterareusuallyconsumedinaday?
WellnessSpecialist:
Datereviewed:
5
Thankyoufortakingthetimetofilloutthisquestionnaireaboutyourhealth.Thiswillgiveyourwellnessspecialistabetterideaofyour
healthstateandcurrentchiefcomplaints.Inaddition,thisinformationwillhelpguideusforamoretailoredapproachtoyourhealthand
wellbeing.Weareheretoansweryourquestionsandeducateyouoninformationyoumayormaynotknowaboutyourhealth.Ifwedo
notknowtheansweroffhand,weareopentodoingtheresearchinordertogiveyouthemostuptodateanswerpossible.
X_________________________________
(signature)
By signing here, you are acknowledging that
**this is not meant to substitute for a physician consultation. Always consult with your physician before making any
modification or alteration to medication regimen.**
WellnessSpecialist:
Datereviewed:
6