Patient Information
Sex:
May we leave a voicemail?
Present Complaints
6. Severity of problem (choose one):
9. Do your symptoms include pain:
Gastrointestinal:
Neurological:
Metabolic:
Hormonal:
10. Do your symptoms occur at a specific time, place, or environment:
11. What types of treatment have you received:
On a scale of 1 to 10, what is your motivation level to achieve these goals:
14. How often are you aware of your main problem (choose one):
16. Due to your condition have you lost time from (describe how much time and what tasks have been limited)?
Work:
Family:
Leisure Activities:
Medications
Have you been exposed to:
Mold:
Heavy Metals:
EBV/Lyme:
Mercury Fillings:
Medical & Social History
Marital Status:
Do you:
Drink Alcohol:
Use Caffeine:
Smoke (Tabacco, E-Cigs, or anything else):
Chew Tobacco:
Review of Symptoms: Past & Current
Have you ever had the following (Choose P for Past, C for Current, or N if you do not or have not experienced the symptom):
P
C
N
Constitutional
Eyes
Ear, Nose, Mouth, & Throat
Psychiatric
Musculoskeletal
Integumentary (Skin & Breasts)
Cardiovascular
Genitourinary
Neurological
Gastrointestinal
Respiratory
Endocrine
Hematologic, Lymphatic, or Other