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Where did you find us
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Who referred you?
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Which specialists do you see?
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Do you use online scheduling
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Phone appointment reminders?
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Text appointment reminders
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Want access to online portal
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Email appointment reminders
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Anything special we need to know
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Major health concern
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Major health concern
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Major health concern
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Major health concern
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Major health concern
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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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Diarrhoea
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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/bendin
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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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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 menopausal
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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 you 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 you eat
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List 3 healthy food you eat
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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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