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Chief Complaint
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Where is it located: (check all the apply to you)
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How does it feel? (check all the apply to you)
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How severe is the pain?
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Pain Scale
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How often does the problem occur? (check all the apply to you)
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How long does it last?
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What improves or worsens it? (check all the apply to you)
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Past Medical History (check all the apply to you)
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Type other past medical conditions here:
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Past Surgical History
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Past Hospitalization History: (Please list all hospitalizations with dates, if not exact dates, then year hospitalized.)
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History and Physical Part 2
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Gut (check all the apply to you)
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Explanation for Gut Issues
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Brain (check all the apply to you)
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Explanation for Brain Issues
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Energy Issues (Please explain: How is your energy in morning, noon and at 2 pm? Do you have cravings for carbohydrates?)
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Sleep: (What time do you go to sleep? Do you wake up in the middle of the night? Is your sleep interrupted? Are you refreshed?)
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Thyroid
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Explanation for Thyroid Issues
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CV/Glucose/Insulin (Explain any issues you might have)
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Blood Pressure/Heart Rate/Heart Rate Variability: (Carb craving? Need to eat every 2 hours? Are you very irritable?)
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Liver/Lymph/Kidneys (Explain any issues you might have)
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Detox/Metals/Liver (Explain any issues you might have)
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Hormones (Explain any issues you might have)
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Women (Please tick if applicable)
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When did you start your menses? Were they regular? Heavy bleeding? Any symptoms of PMS? Cramping? Flashes? Sweats? Tenderness?
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PCOS
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Explanation of any PCOS conditions
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Men (Please tick if applicable)
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Energy, strength, endurance? How is your stamina in the bedroom?
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Erectile Function: (On a scale of 1-10 where do you think you are at from when you were younger now?)
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Musculoskeletal (Any aches, joint, pains, muscle aches?)
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Any Allergies?
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Medications Currently Taking: (Please include any supplements, oils or other natural medications that you are currently taking.)
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Significant Family History?
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Social History
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Caffeine Use (Include tea, coffee, soda, caffeine pills, or green tea consumption)
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Alcohol Consumption
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Recreational Drugs Currently Taking
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Smoking Status (Include how often and how many packs a day please)
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