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Category 1
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Bowels do not empty completely
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Lower abdominal pain relief
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Alternating constipation
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Diarrhea
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Constipation
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Hard,dry or small stool
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Debris on tongue
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Pass smelling gas
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more than 3 bowel movement
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Use laxatives frequently
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Category II
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Excessive belching/burping
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Gas immediately after meal
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Offensive breath
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Difficult bowel movement
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Sense of fullness after meal or
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Difficulty digesting fruits/vege
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Undigested foods found in stool
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Category III
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Stomach pain1-4 hrs after eating
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Use antacids
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Feel hungry 1/2 after eating
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Heartburn when lying down or ben
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Temporary relief from antacids
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Digestive problems
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Heartburn due to spicy food
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Category IV
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Roughage/fiber cause constipatio
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Indigestion/fullness after eatin
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Pain on left side of the rib cag
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Excessive passage of Gas
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Stool undigested/foul smelling
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Frequent urination
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Increased thirst and appetite
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Difficulty losing weight
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Category V
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Greasy foods cause disstress
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Lower bowel gas
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Bloating several hours after eat
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Bitter metallic taste in mouth
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unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates
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Reddened skin especially palm
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Dry/flaky hair or skin
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History of gallbladder
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Had gallbladder removed
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Category VI
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Crave sweets during the day
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Irritable if meals are missed
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Depend on coffee to keep going
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Gets lightheaded if meals missed
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Eating relieves fatigue
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Feel shaky or jittery
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Agitated,easily upset
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Poor memory/forgetful
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Blurred vision
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Category VII
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Fatigue after meals
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Crave sweets during the day
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Eating sweets does not relieve
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Must have sweets after meal
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Waist girth is equal than hip gi
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Frequent urination
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Increased thirst and appetite
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Difficulty loosing weight
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Category VIII
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Cannot stay asleep
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Crave Salt
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Slow starter in the morning
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Afternoon fatigue
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Dizziness when standing up quick
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Afternoon headaches
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Headaches with exertion or stres
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Weak nails
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Category IX
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Cannot fall asleep
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Perspier easily
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Under high amounts of stress
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Weight gain when under stress
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Wake up tired even after 6 hrs s
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Excessive perspiration
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Category X
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Tired or sluggish
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Feel cold all over
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Require excessive sleep
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Increase in weight gain
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Gain weight easily
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Infrequent bowel movement
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Depression,lack of motivation
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Morning headaches
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Outer third of eyebrow thins
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Thinning of hair on scalp
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Dryness of skin/scalp
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Mental sluggishness
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Category XI
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Heart Palpitations
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Inward trembling
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Increased pulse even at rest
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Nervous and emotional
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Insomnia
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Night sweats
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Difficulty gaining weight
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Category XII
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Diminished sex drive
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Menstrual disorders
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Inc. ability to eat sugars
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Category XIII
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Increased sex drive
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Tolerance to sugars reduce
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"splitting" type headaches
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Category XIV(males Only)
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Urination Difficulty
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Frequent Urination
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Pain inside of legs or heels
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Incomplete bowel evacuation
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Legs nervousness at night
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Category XV(Males only)
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Decrease in libido
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Decrease in morning erection
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Decrease in fullness of erection
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Difficulty in maintaining erecti
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Spells of mental fatigue
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Inability to concentrate
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Episodes of depression
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Muscle soreness
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Decrease in physical stamina
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Unexplained weight gained
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Increase in fat distribution
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Sweating attacks
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More emotional than in past
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Category XVI(FEMALE ONLY)
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Are you perimenopausal
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Alternating menstrual cycle
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Extended menstrual cycle
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Shortened menses
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Pain/cramping during period
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Scanty blood flow
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Heavy blood flow
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Breast pain during menses
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Pelvic pain during menses
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Irritable & depressed during men
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Acne breakouts
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Facial hair growth
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Hair loss/thinning
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Category XVII(FEMALE ONLY)
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years you have been menopausal
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Ever have uterine bleeding
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Hot flashes
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Mental fogginess
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Disinterest in sex
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Mood swings
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Depression
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Painful intercourse
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Shrinking breast
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Facial hair growth
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Acne
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Increased vaginal pain
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Alcohol you consume per week
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Caffeinated beverage you consume
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Times u eat out per week
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Times you eat nuts
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How many times u eat fish
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Times u do workouts
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List 3 worst food
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List 3 healthy food
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Do you smoke
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If yes, How many
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Rate stress level1-10
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Natural supplements that you tak
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Section A
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Memory Declining
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Hard time remembering name
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Ability to focus declining
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Harder to learn things
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Hard time remembering appointmen
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Temperament getting worse
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Loosing attention span
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Found yourself down or sad
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Fatigue when driving
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Fatigue when reading
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Walk into rooms& forget why
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Pick up ur cellphone & forget wh
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Section B
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How high is stress level
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Feel that sumthing must be done
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Feel never have time for urself
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Not getting enough sleep
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Difficult to get exercise
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Feel uncared
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Not accomplishing life purpose
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Difficulty is sharing problems
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Section C
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Section C1
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How often u get irritable
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Feel energised after eating
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Difficulty eating large meals
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Energy level drop in afternoon
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Crave sugar in afternoon
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Wake up in the middle o night
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Difficulty concentrating
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Depend on coffee
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Feel agitated or easily upset
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Section c-2
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Fatigued after meal
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Crave sugar and sweets
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Need stimulants after meals
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Difficulty loosing weight
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Waist girth larger than hip girt
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How often do you urinate
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Thirst/appetite increased
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Weight gain under stress
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Difficulty falling asleep
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Section 1-S
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Loosing pleasure in hobbies
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Overwhelmed with ideas
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Feelings of inner rage
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Feelings of paranoia
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Feel sad or down for no reason
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Feel like nt enjoying life
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Lack artistic appreciation
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Depressed in overcast weather
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Loosing enthusiasm in fav activi
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Losing enjoyment for fav food
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Losing enjoyment of friendship
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Difficulty falling deepsleep
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Feeling of dependency on other
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Feel more susceptible to pain
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Feeling of unprovoked anger
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Losing interest in life
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Section 2D
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Feeling of hopelessness
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Self destructive thoughts
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Inability to handle stress
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Anger while under stress
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Feel not rested even after long
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Prefer to isolate yourself
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Unexplained lack of concerns
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Easily distracted from task
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Inability to finish task
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Feel to consume caffeine
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Libido has been decreased
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Lose temper for minor reason
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Feeling of worthlessness
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Section 3-G
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Feel anxious for no reason
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Feeling of dread
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Feel knots in your stomach
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Feeling of being overwhelmed
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Feeling of guilt for every decis
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Mind feels restless
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Turn of your mind when relax
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Disorganized attention
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Worry about things
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Feeling of inner tension
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Section 4 ACH
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Visual memory decreased
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Verbal memory decreased
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Have memory lapses
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Creativity been decreased
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Comprehension been diminished
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Difficulty calculating numbers
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Difficulty recognising objects
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Your opinion about yourself chan
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Excessive urination
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Slow mental response
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Medication history
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Antimuscarinic Agents
• • •
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Ganlionic Blockers
• • •
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Acetylcholinesterase reactivator
• • •
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Neuromuscular Blockers
• • •
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Gaba receptor
• • •
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nonbenzodiazpines
• • •
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Cholinesterase(irreversible)
• • •
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Cholinesterase (reversible)
• • •
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Dopamine reuptake
• • •
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Dopamine receptor
• • •
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D2 Dopamine receptor
• • •
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GABA Antagonist
• • •
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Monoamine oxidase
• • •
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Noradrenergic
• • •
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Selective Serotonin
• • •
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Serotonin Enhancers
• • •
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Serotonin-norepinephrine
• • •
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Tricylic Antidepresseants
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care of your health in past
• • •
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Other care of your health
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previous method(s) work out
• • •
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Others affected by health condit
• • •
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Afraid this might affect
• • •
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Health condition you are afraid
• • •
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Other health conditions
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Health affected your job
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Health affected your realtionshi
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Health affected your finances
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Health affected your family
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Health affected other acivities
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What has that cost you
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What are you most concerned
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If problem is not taken care
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Where u see urself next 1/3 yrs
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Different without problem
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Desire to get working with us
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What is that worth to you
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Health questionnaire
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When did your symptoms start
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Describe your symptom
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How symptom began
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what is the cause for ur problem
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Experiencing pain or symptoms
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How long have you been in pain
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How often you experience symptom
• • •
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Experience symptom
• • •
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Diagrams
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How are your symptoms changing
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Notice symptom the most
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How long do they last
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How bad are your symptoms when
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symptoms at their worst
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symptoms at their best
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Symtoms Now
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Symptoms affect daily activity
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What makes your symptoms worse
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What makes your symptoms better
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Who have you seen for symptom
• • •
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Any other specialist seen
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When and what treatment
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Had Xray Test
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Date
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MRI Test
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Date
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CT Scan
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Date
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Other test
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Date
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Had similar symptom in past
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If yes, How often
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When was the last time
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Who treated you
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Any other
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Are you pregnant
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last menstrual period
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Hope to get from this visit
• • •
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Any other hopes
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Lost time frm work
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If yes, how much
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Family member suffer same proble
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What are your hobbies
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Rate your general health state
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What is your occupation
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Activities does ur job require
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Marital Status
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Highest level of education
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Type of regular exercise
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Height/ weight
/
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Do you use tobacco
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If yes, How much
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Do you drink alcoholic beverages
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If yes, how much
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Do you use illicit drugs
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If yes, how much & what kind
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Family member had any the below
• • •
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Any other disease
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List all surgical procedure
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List major illness
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Major injury dates
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Signature
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