intake forms · naturopathic consult - client intake forms dr. keri brown, nd [email protected]...

Naturopathic Consult - Client Intake Forms

Dr. Keri Brown, ND www.drkeribrown.com [email protected] 970-889-3541

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Intake Forms

Date______________________

Name: ______________________________________________________________________________

Mailing Address ___________________________________________________________ Apt No.________

City/State __________________________________________________________________ Zip Code__________

Shipping Address _________________________________________________________

City/State _________________________________________________________________ Zip Code__________

Phone (home) ______________________________ Cell Phone_______________________________________

Work Phone ______________________________ Fax_____________________________________________

E-mail _______________________________________________________________________________________

Emergency Contact: _________________________________________________________________

Address ___________________________________________________________________________

City/State _________________________________________________________________ Zip Code__________

Phone (home/cell)_______________________________ Work Phone ___________________________________

Age _________ Date of Birth _________________ Gender Female Male

Genetic Background ___ African ___ European ___ Native American ___ Mediterranean

___ Asian ___ Middle Eastern ___ Other__

Higher Education Level: High School____ Under-Graduate____ Post-Graduate____

Occupation ______________________________________________________________________

Employer by _____________________________________________________________________

Referred by ______________________________________________________________________

____ Media (Please indicate source)__

____ Online (Google\Please list search words you used to find us)__

____ Health Care Organization: __

____ Friend or Family Name: __

____ Other__

Current/Recent healthcare providers

Name Dates Care Provided

____________________________________________________________________________________________________

Authorization to Provide Information; this health consultation is to provide you with alternative suggestion for

healthcare only. It is up to you to make your own decision on what you will do for your health regarding testing,

supplements, and alternative care.

Signature: _____________________________________________________ Date: ___________________

Print Name: ___________________________________________________

http://www.drkeribrown.com/



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We understand that this is an extensive form. Get yourself a glass of water or tea, take your time. This form provides a big picture to your health. If you could erase 3 problems, what would they be? 1.______________________________________________________________________________________________________________ 2.______________________________________________________________________________________________________________ 3.______________________________________________________________________________________________________________ When was the last time you felt well? ________________________________________________________________________________________________________________ Did something trigger your change in health? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What makes you feel worse? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What makes you feel better? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please list current and ongoing problems in order of priority

Describe Problem Mild Mod. Severe Prior Treatment Approach

Good Fair Bad

Example: Post Nasal drip x Elimination Diet x

MEDICAL HISTORY DIAGNOSIS/CONDITIONS/DISEASES This is a list of any problems you might have had or have. Check appropriate box and provide date of onset. Gastrointestinal ___ Irritable Bowel Syndrome __________ ___ Inflammatory Bowel Disease __________ ___ Crohn’s __________ ___ Ulcerative Colitis __________ ___ Peptic Ulcer Disease __________

___ GERD (Reflux) __________ ___ Celiac Disease __________ ___ Gall Bladder __________ ___ Other ___________________________

Cardiovascular ___Heart Attack __________ ___Other Hearth Disease __________ ___ Stoke __________ ___ Elevated Cholesterol __________ ___ Arrhythmia (irregular heart rate) __________

___ Hypertension (high blood pressure) __________ ___ Rheumatic Fever __________ ___ Mitral Valve Prolapse __________ ___ Other ___________________________

Metabolic/Endocrine ___ Type 1 Diabetes __________ ___ Type 2 Diabetes __________ ___ Hypoglycemia __________ ___ Metabolic Syndrome __________ ___ Pre-Diabetes __________ ___ Hypothyroidism (low thyroid) __________ ___ Hyperthyroidism (overactive) __________ ___ Endocrine Problems __________ ___ Polycystic Ovarian Syndrome __________ ___ Infertility __________

___ Weight Gain __________ ___ Weight Loss` __________ ___ Weight Fluctuations __________ ___ Bulimia __________ ___ Anorexia __________ ___ Binge Eating Disorder __________ ___ Night eating Syndrome __________ ___ Eating Disorder (non-specific) __________ ___ Other __________________________




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Genital and Urinary System ___ Kidney Stones __________ ___ Gout __________ ___ Interstitial Cystitis __________ ___ Urinary Tract Infections __________

___ Yeast Infections __________ ___ Erectile/Sexual Dysfunction __________ ___ Other ___________________________

Musculoskeletal/Pain ___ Osteoarthritis __________ ___ Osteoporosis __________ ___ Osteopenia __________

___ Fibromyalgia __________ ___ Chronic Pain __________ ___ Other ___________________________

Inflammatory/Autoimmune ___ Chronic Fatigue Syndrome __________ ___ Autoimmune Disease __________ ___ Rheumatoid Arthritis __________ ___ Lupus SLE __________ ___ Immune Deficiency Disease __________ ___ Herpes-Genital __________ ___ Severe Infectious Disease __________

___ Poor Immune Function __________ ___ Frequent Infections __________ ___ Food Allergies __________ ___ Environmental Allergies __________ ___ Chemical Sensitivities __________ ___ Other ___________________________

Respiratory Disease ___ Asthma __________ ___ Chronic Sinusitis __________ ___ Bronchitis __________ ___ Emphysema __________

___ Pneumonia __________ ___ Tuberculosis __________ ___ Sleep Apnea __________ ___ Other ___________________________

Skin Diseases ___ Eczema __________ ___ Psoriasis __________ ___ Acne __________

___ Melanoma __________ ___ Skin Cancer __________ ___ Other ____________________________

Neurologic/Mood ___ Depression __________ ___ Anxiety __________ ___ Bipolar Disorder __________ ___ Schizophrenia __________ ___ Headaches __________ ___ Migraines __________ ___ Autism __________

___ Mild Cognitive Impairment __________ ___ Memory Problems __________ ___ Parkinson’s Disease __________ ___ Multiple Sclerosis __________ ___ ALS __________ ___ Seizures __________ ___ Other ____________________________

Injuries ___ Back Injury __________ ___ Head Injury __________ ___ Neck Injury __________ ___ Knee Injury __________

___ Ankle Injury __________ ___ Broken Bones __________ ___ Other __________________________

Cancer ___ Lung Cancer __________ ___ Breast Cancer __________ ___ Colon Cancer __________ ___ Ovarian Cancer __________

___ Prostate Cancer __________ ___ Skin Cancer __________ ___ Other ___________________________

Surgeries ___ None ___ Appendectomy __________ ___ Hysterectomy __________ ___ Gall Bladder __________ ___ Hernia __________ ___ Tonsillectomy __________ ___ Dental Surgery __________

___ Joint replacement __________ Knee ___ Hip ___ ___ Heart Surgery __________ ___ Angioplasty or Stent __________ ___ Pacemaker __________ ___ Other __________________________

EVERY HAD A HEAD INJURY OR CAR ACCIDENT Yes _____ N0 ______




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Preventive Tests and Dates ___ Full Physical Exam __________ ___ Bone density __________ ___ Colonoscopy __________ ___ Cardiac Stress Test __________ ___ Heart Scan/ EKG __________ ___ Hemoccult (stool/blood) Test __________

___ MRI __________ ___ CT Scan __________ ___ Upper Endoscopy __________ ___ Upper GI Series __________ ___ Ultrasound __________

Blood Type & Physical Attributes ___ A ___ B ___ AB ___ O ___ Rh ___ Rh+ ___ Unknown ***********Height (feet/inches) _______ Usual weight range +/- 5 lbs. _______ Highest adult weight _______ Weight fluctuations (>10 lbs.) _______

Current weight _______ Desired weight range +/- 5 lbs. _______ Lowest adult weight _______ Body fat % _______

Hospitalization ___ None

If yes, list Date Reason

Dental History ___ Silver Mercury Fillings If yes, how many? ____ ___ Gold Fillings ___ Root Canals If yes, how many? ____ ___ Implants ___ Tooth Pain

___ Teeth Loose ___ Bleeding Gums ___ Gingivitis ___ Problems with Chewing Do you floss regularly ___ Yes ___ No

WOMEN’S HISTORY (For Women Only) Menstrual History Age of First Period __________ Menses Frequency __________ Length __________ Last Menstrual Period ________________ Pain ___ Yes ___ No

If yes, it is better with ___Warmth ___Pressure ___Doubling over ___ Arching back ___ Other _____ Clotting ___ Yes ___ No Has your period ever skipped? ___ Yes ___ No If yes, for how long? _____________________________________________________________________ Do you use hormonal contraception? ___ Yes ___ No ___ Birth Control Pills ___ Patch ___ Nuva Ring If yes, for how long? ____________________________________________________________________ Do you use contraception? ___ Yes ___ No ___ Condom ___ Diaphragm ___ IU ___ Partner Vasectomy Hormonal Imbalances___ Fibrocystic Breasts ___ Infertility

___ PMS ___ Endometriosis

___ Painful Periods ___ Fibroids

___ Heavy Periods

Last Mammogram __________ Last PAP test __________ Last Bone Density __________

Breast Biopsy ___ Yes ___ No If yes, Date __________ Results ___ Normal ___ Abnormal

Are you in menopause? ___ Yes ___ No If yes, Age of Menopause ________________________________________________________________________________ ___ Hot Flashes ___ Vaginal Dryness ___ Joint Pains ___ Loss of Control of Urine ___ Mood Swings

___ Decreased Libido ___ Headaches ___ Palpitations

___ Concentration/Memory ___ Heavy Bleeding ___ Weight Gain

Use of hormone replacement therapy ___ Yes ___ No If yes, for how long? ___

MEN’S HISTORY (For Men Only)




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Have you had a PSA done ___ Yes ___ No If yes, PSA level ___ 0-2 ___ 2-4 ___ 4-10 ___ >10

Has your PSA been slowly raising over time ___ Yes ___ No ___ Prostate Enlargement ___ Impotency ___ Prostate Infection ___ Difficulty Obtaining an Erection ___ Change in Libido

___ Difficulty Maintaining an Erection ___ Nocturia (urination at night) ___ Urgency/Hesitancy/Change in Urinary Stream ___ Loss of Control of Urine

CURRENT MEDICAL HISTORY MEDICATIONS Current Medications

Medication Dose Frequency Start date (m0/yr) Reason for Use

Previous Medications (Last 10 years)

Medication Dose Frequency Start date (m0/yr) Reason for Use

Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathic)

Supplement & Brand Dose Frequency Start date (m0/yr) Reason for Use

MEDICATIONS (Continue) Have your medications or supplements ever caused you unusual side effects or problems? ___ Yes ___No Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin? ___ Yes ___No Have you had prolonged or regular use of Tylenol? ___ Yes ___No Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec) ___ Yes ___No Frequent Antibiotic >2 times a year ___ Yes ___No Long term antibiotic use ___ Yes ___No Use of steroids (prednisone, nasal allergy inhalers) in the past ___ Yes ___No Environmental and Detoxification Assessment Do you have known food reactions or sensitivities ___ Yes ___ No If yes, describe symptoms ___ Do you have any known chemical sensitivity ___ Yes ___ No If yes, describe symptoms ___ Do you have an adverse reaction to caffeine ___ Yes ___ No

If yes, when you drink caffeine do you feel ___ Irritable or wired ___ Aches & pains Do you have adverse reactions to (Check all that apply) ___ Alcohol ___ Chocolate ___ Onion




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___ Citrus Foods ___ Red Wine ___ Caffeine ___ Garlic

___ Night Shade Plants (Potatoes/tomatoes) ___ Cheese ___ Aspartame/NutraSweet

___ Monosodium glutamate (MSG) ___ Sulfite Containing Foods (Wine, dried fruit, salad bars)

Do any of these significantly affect you ___ Cigarette Smoke ___ Perfumed/Colognes ___Auto Exhaust Fumes ___ Other ____________ In your work or home environment, are you exposed to ___ Chemicals ___ Mold

___ Electromagnetic Radiation ___ Other __________________________________________

Do you have a known history of significant exposure to any harmful chemicals such as the following? ___ Herbicides ___ Pesticides ___ Organic Solvents

___ Heavy Metals ___ Insecticides ___ Other __________________________________________

If yes, Chemical name, date and exposure

time ______________________

_________________________________________

Have you ever been jaundice (turned yellow) ___ Yes ___ No Do you dry clean your clothes frequently ___ Yes ___ No Do you polish your nails or dry your hair frequently ___ Yes ___ No Do you have pets or farm animals’ ___ Yes ___ No Sleep Average number of hours you sleep per night ___ <6 ___6-8 ___ 8-10 ___< 10 Do you sleep well? ___ Yes ___No Do you have trouble falling asleep ___ Yes ___No Do you wake up at night? What Time _________? ___ Yes ___No If so, do you go back to sleep ___ Yes ___No Do you have problems with insomnia ___ Yes ___No Do you use sleeping aids ___ Yes ___No Explain: __ Do you awake rested ___ Yes ___No What position do you sleep in ___ Right side ___ Left side ___ Back ___ Stomach Do you have recurring dreams ___ Yes ___No Explain: __ Do you have nightmares ___ Yes ___No What is your best time of day ___ 8-11 am ___ 12-4 pm ___4-8pm ___8-11 pm What is your worst time of day ___ 8-11 am ___ 12-4 pm ___4-8pm ___8-11 pm Exercise Current Exercise Program (List the type of actively, number of sessions/week and duration)

Activity Type Frequency per week Duration of minuets

Nutrition History Have you ever had a nutritional consultation ___ Yes ___ No Have you made any changes to your diet because of your health ___ Yes ___ No If yes, please describe __ Do you currently follow a specific diet or nutritional program ___ Yes ___ No Check all that apply ___ Low fat ___ No Dairy ___ Low Carbohydrates ___ High Protein

___ Low Sodium ___ Diabetic ___ No Wheat ___ Gluten restricted

___ Vegetarian ___ Vegan ___ Other __

Known food allergies ___ Wheat ___ Dairy ___ Corn ___Citrus ___ Egg ___ Alcohol ___ Others ___

Do you grocery shop ___ Yes ___ No Do you read labels ___ Yes ___ No Do you cook ___ Yes ___ No How many meal meals do you eat out per week ___ 0-1 ___ 1-3 ___ 3-5 ___ >5 meals Check all that apply to you eating habits The most important thing I should change about my diet to improve my health is ________________________________________________________________________________________________________________




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What foods do you crave? ___ Sweets ___ Chocolate ___ Salty ___ Sour ___Breads ___ Fatty ___ Spicy ___Other_______________________________________________________________________________

Do you have any immediate symptoms in associations with eating ___ Yes ___ No ___ Belching ___ Bloating ___ Abdominal pain ___Diarrhea ___ Hives ___ Post Nasal Drip Do fatty foods cause indigestion ___ Yes ___ No Do you feel you have delayed symptoms to eating certain foods (up to 24/48 hours or more) ___ Yes ___ No

If yes, what kind __ What foods, when you eat them, make you worse ___ Does skipping a meal greatly affect you ___ Yes ___ No If yes, what happens ___ How often do you eat How many times a day ______? Are you thirsty ___ Yes ___ No Elimination Habits

Do you have bowel movement daily ___ Yes ___ No Frequent diarrhea ___ Yes ___ No

If yes, are they explosive ___ Yes ___ No How many times a day ______________

Constipated often ___ Yes ___ No If yes, how many day between _____________ Offensive odor ___ Yes ___ No Are they well-formed ___ Yes ___ No

Difficult to pass ___ Yes ___ No Do they float ___ Yes ___ No Are they thin ___ Yes ___ No Are they hard small balls ___ Yes ___ No Watery ___ Yes ___ No Hard ___ Yes ___ No Loose ___ Yes ___ No Is blood ever seen ___ Yes ___ No

What color is your stool ___ Grey ___Light Tan ___ Brown ___ Black Do you have intestinal gas

Occasionally: _____ Daily: _____ Excessive: _____ Offensive odor ___ Yes ___ No

How many times day do you urinate ___ 1-3 ___4-7 ___8-12 ___13-20 Do you perspire easily ___ Yes ___ No Psychosocial History Do you feel significantly less vital than you did a year ago ___ Yes ___ No Are you happy ___ Yes ___ No Do you feel your life had meaning and purpose ___ Yes ___ No Do you believe stress is presently reducing the quality of your life ___ Yes ___ No Have you ever experienced major losses in your life ___ Yes ___ No Do you get angry easy ___ Yes ___ No Do you get irritable ___ Yes ___ No Are you impatient ___ Yes ___ No Are you critical ___ Yes ___ No Do you worry much ___ Yes ___ No If yes, what do you worry about __ Is there anything unusual or remarkable about you? Stress/Coping Do you have an excessive amount of stress in your life ___ Yes ___ No Do you feel you can easily handle the stress in your life ___ Yes ___ No Daily Stressors (rate on a scale of 1-10, 10 being the most stressful)Work _______ Family _______

Social _______ Finances _______

Health _______ Other __

Do you practice relaxation techniques or meditation ___ Yes ___ No If yes, how often __ Check all that apply ___ Yoga ___ Mediation ___ Imagery

___ Breathing ___ Tia Chi ___ Prayer

___ Other __

Have you ever been abused, a victim of a crime or experienced a significant trauma ___ Yes ___ No



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Dr. Keri Brown, N.D. Naturopathic Integration 970-889-3541 [email protected]

Memory Screening Rate the following questions Never=1 Rarely=2 Occasionally=3 Regularly=4 Daily=5

Forgetting where you have put something, losing things around the house ___1 ___ 2 ___ 3 ___ 4 ___ 5

Failing to recognize places that you have been before ___1 ___ 2 ___ 3 ___ 4 ___ 5

Having to go back to check whether you have done something that you meant to do ___1 ___ 2 ___ 3 ___ 4 ___ 5

Completely forgetting to take things with you, having to go back and fetch them ___1 ___ 2 ___ 3 ___ 4 ___ 5

Forgetting that you were told something yesterday or a few days ago ___1 ___ 2 ___ 3 ___ 4 ___ 5

Forgetting details of what you did or what happened the day before ___1 ___ 2 ___ 3 ___ 4 ___ 5

When talking to someone, forgetting what you have just said “What was I talking about?” ___1 ___ 2 ___ 3 ___ 4 ___ 5

When reading a newspaper, being unable to follow the story or loss track ___1 ___ 2 ___ 3 ___ 4 ___ 5

Getting the details of what someone told you mixed up ___1 ___ 2 ___ 3 ___ 4 ___ 5

Telling someone a story or joke you have already told them ___1 ___ 2 ___ 3 ___ 4 ___ 5

Forgetting details of things, you do regularly ___1 ___ 2 ___ 3 ___ 4 ___ 5

Getting lost or turning the wrong direction on a journey or walk ___1 ___ 2 ___ 3 ___ 4 ___ 5

Repeating to someone what you have just told them or asking the same question twice ___1 ___ 2 ___ 3 ___ 4 ___ 5

Family History Please indicate if any family member has had and/or died from any of the following: (Relationship & Age)

Self Mother Father Sisters Brothers Children Gndparent (Mother’s)

Gndparent (Father’s)

Aunt/Uncle

Alcoholism

Drug Addiction

Allergies

Asthma

Inflammatory Arthritis (Rheumatism, Psoriatic)

Inflammatory Bowel

Cancer

Breast Cancer

Diabetes

Eczema / Psoriasis

Genetic Disease

Glaucoma

Heart Disease

High Cholesterol

Immune Disorder

High Blood Pressure

Kidney Disease

Mental / Nervous d/o

Osteoporosis

Parkinson’s

Psychiatric Disorder

Depression

Schizophrenia

Bipolar Disease

Stomach Ulcers

Stroke

Thyroid Disorders

Other (Please describe)

SYMPTOM SURVEY FORM

INSTRUCTIONS: Check in only the boxes which apply to you.

1 2 3

x MILD symptoms (occurred once or twice in last 6 months)


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x MODERATE symptoms (occurred once or twice last month)

x SEVERE symptoms (chronic, occurred once or twice last week)

52 Awaken safer few hours’ sleep – hard to get back to sleep 53 Craves candy or coffee in afternoon 54 Moods of depression – ‘blues’

55 Abnormal craving for sweets or snacks

GROUP 4

56 Hands and feet go to sleep easily 57 Sigh frequently, ‘air under’ 58 High altitude discomfort 60 Opens windows in closed rooms 61 Susceptible to colds and fevers 62 Afternoon ‘yawner’ 63 Get “Drowsy” often 64 Swollen ankles, worse at night 65 Muscle cramps, worse during exercise; gets ‘charley horses’ 66 Shortness of breath on exertion 67 Dull pain in chest or radiation into left arm, worse on exertion 68 Bruise easily, ‘black and blue’ spots 69 Tendency to anemia 70 ‘Nose bleeds’ frequently 71 Noises in head, or ‘ringing in ears’ 72 Tension under the breastbone, ‘tightness’ worse on exertion

GROUP 5

73 Dizziness 74 Dry skin 75 Burning feet 76 Blurred vision 77 Itching skin and feet 79 Frequent skin rashes 80 Bitter, metallic taste in mouth in morning 81 Bowel movement painful or difficult 82 Worrier, feels insecure 83 Feels queasy; headache over eyes 84 Greasy food upset 85 Stools light colored 86 Skin peels on foot soles 87 Pain between shoulder blades 88 Use laxatives 89 Stools alternating from soft to watery 90 History of gallbladder attach sot gallstones 91 Sneezing attacks 92 Dreaming, nightmares type bad dreams 93 Bad breath (halitosis) 94 Milk products causes distress 95 Sensitivity to hot water 96 Burning or itching anus 97 Craves sweets

GROUP 6

98 Loss of taste for meat 99 Lower bowel gas several hours after eating 100 Burning stomach sensation, eating relieves 101 Coated tongue

102 Pass large amounts of foul-smelling gas

103 Indigestion ½-1 hours after eating; may be up to 3-4 hours

104 Mucous colitis or ‘irritable bowel’

105 Gas shortly after eating

106 Stomach ‘bloated’ after eating

1 2 3 GROUP 1

1 Acid foods upset 2 Get chilled often 3 “Lump” in throat 4 Dry mouth-eyes-nose 5 Pulse speeds after meals 6 Keyed up – fail to calm 7 Cut heals slowly 8 Gag easily 9 Unable to relax, startles easily 10 Extremities cold, clammy 11 Strong light irritates 12 Urine amount reduced 13 Heart pounds after retiring 14 “Nervous” stomach 15 Appetite reduced 16 Cold sweats often 17 Fever easily raised 18 Skin sensitive to touch 19 Staring, blinks little 20 Sour stomach often

GROUP 2

21 Joint stiffness on arising 22 Muscle-leg-toe cramps at night 23 “Butterfly” stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen, puffy 27 Indigestion soon after eating 28 Always seems hungry; “lightheaded” often 29 Digestion rapid 30 Vomiting frequent 31 Hoarseness frequent 32 Breathing irregular 33 Pulse slow; feels “irregular” 34 Gagging reflex slow 35 Difficulty swallowing 36 Constipation, diarrhea alternation 37 ‘Slow starter’ 38 Gets ‘chilled’ infrequently 39 Perspire easily 40 Circulation poor, sensitive to cold 41 Subject to colds, asthma, bronchitis

GROUP 3

42 Eat when nervous

43 Excessive appetite 44 Hungry between meals 45 Irritable before meals 46 Get ‘shaky’ if hungry 47 Fatigue, eating relieves 48 ’Lightheaded’ if meals delayed 49 Heart palpated if meals missed or delayed 50 Afternoon headaches 51 Overeating sweets upsets

169 Allergies – tendency to asthma 170 Weakness after colds, influenza 171 Exhaustion – muscular and nervous 172 Respiratory disorders

GROUP 8

173 Apprehension 174 Irritability 175 Morbid fears 176 Never seems to get well 177 Forgetfulness 178 Indigestion 179 Poor appetite 180 Craving for sweets 181 Muscular soreness 182 Depression, feeling of dread 183 Noise sensitivity 184 Acoustic hallucinations 185 Tendency to cry without reason 186 Hair is course and/or thinning 187 Weakness 188 Fatigue 189 Sin sensitive to touch 190 Tendency towards hives 191 Nervousness 192 Headaches 193 Insomnia 194 Anxiety 195 Anorexia 196 Inability to concentrate, confusion 197 Frequent stuffy nose, sinus infection 198 Allergy to some foods 199 Loose joints

FEMALE ONLY

200 Very easily fatigues 201 Premenstrual tension 202 Painful menses 203 Depressed feeling before menstruation 204 Menstruation excessive and prolonged 205 Painful breasts 206 Menstruate too frequently 207 Vaginal discharge 208 Hysterectomy / ovaries removed 209 Menopausal hot flashes 210 Menses scanty or misses 211 Acne, worse at menses 212 Depression of long standing

MALE ONLY

213 Prostate trouble 214 Urination difficult or dribbling 215 Night urination frequency 216 Depression 217 Pain on inside of legs or heels 218 Feeling of incomplete bowel evacuation 219 Lack of energy 220 Migration aches and pains 221 Tire too easily 222 Avoids activity 223 Legs nervousness at night 224 Diminished sex drive


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GROUP 7

107 Insomnia 108 Nervousness 109 Can’t gain weight 110 Intolerance to heat 111 Highly emotional 112 Flushes easily 113 Night sweats 114 Thin, moist skin 115 Inward trembling 116 Heart palpitates 117 Increased appetite without weight gain 118 Pulse fast at rest 119 Eyelids and face twitch 120 Irritable and restless 121 Can’t work under pressure

GROUP 7B

122 Increased weight gain 123 Decreased in appetite 124 Fatigue easily 125 Ringing in ears 126 Sleepy during the day 127 Sensitive to cold 128 Dry or scaly skin 129 Constipation 130 Mental sluggishness 131 Hair course, falls out 132 Headaches upon arising, wear off during the day 133 Slow pulse, below 55 134 Frequency of urination 135 Impaired hearing 136 Reduced initiative

GROUP 7C

137 Failing memory 138 Low blood pressure 139 Increased sex drive 140 Headaches, ‘splitting or rending’ type 141 Decreased sugar tolerance

GROUP 7D

142 Abnormal thirst 143 Bloating of abdomen 144 Weight gain around hips or waist 145 Sex drive reduced or lacking 146 Tendency to ulcers, colitis 147 Increased sugar tolerance 148 Women: menstrual disorder 149 Young girls: lack of menstrual function

GROUP 7E

150 Dizziness 151 Headaches 152 Hot flashes 153 Increased blood pressure 154 Hair growth on face and body (female) 155 Sugar in urine (not diabetes) 156 Masculine tendencies (female)

GROUP 7F

157 Weakness, dizziness 158 Chronic fatigue 159 Low blood pressure 160 Nails weak, ridged 161 Tendency to hives 162 Arthritis tendencies 163 Perspiration increases 164 Bowel disorder 165 Poor circulation 166 Swollen ankles 167 Craves salt 168 Brown spots or bronzing of skin


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MEDICAL SYMPTOMS QUESTIONNAIRE & TOXICITY LEVEL

Rate and check each of the following symptoms based upon your typical health profile for the last months:

Point Scale Leave blank if you have not experienced a symptom.

1. Place an __x___ on the line if you experience these signs

GENERAL Cold hands & feet ______ Cold intolerance ______ SKIN Acne on back ______ Acne on chest ______ Acne on face ______ Acne on shoulders ______ Athlete’s foot ______ Bumps back of upper arms ______ Eyebrow hair loss ______ Outside eyebrow ______ Inside eyebrow ______ Easy bruising ______ Hair loss (Head) ______ Allover ______

Frontal ______ Spots ______

SKIN, DRYNESS OF Feet/ ______ Cracking ______ Peeling ______ Scalp/Dandruff ______ Scalp/Hair dry in general ______ Skin dry in general ______ NAILS Bitten ______ Brittle ______ Curved up ______ Frayed ______ Fungus – fingers ______

Fungus-toes ______

Pitting ______

Ragged cuticles ______

Ridges ______

Soft ______

Thickening of

Fingernails ______

Toenails ______

White spots/lines ______

LYMPH NODES

Enlarged/Neck ______

Tender/Neck ______

Other enlarged/tender ______

Underarm ______

Inner thigh ______

2. Place a number rate between 1-4 each of the following symptoms based upon your health profile for the last

month.

Point Scale Leave blank if you have not experienced a symptom. 1 - Occasionally experience it, effect is not severe

2 - Occasionally experience it, effect is severe

3 - Frequently experience it, effect is not severe

4 - Frequently experience it, effect is severe

HEAD Headaches _____

Faintness _____

Dizziness _____

Insomnia _____

Total ________

EYES Watery or itchy eyes _____

Swollen, redness or sticky eyelids _____

Bags or dark circles under eyes _____

Blurred or tunnel vision _____

(does not include near- or far-sightedness

Total ________

EARS Itchy ears _____

Earaches, ear infections _____

Drainage from ear _____

Ringing in ears, hearing loss _____

Total ________

NOSE Stuffy nose _____

Sinus problems _____

Hay fever _____

Sneezing attacks _____

Excessive mucus formation _____

Total ________

MOUTH/THROAT

Chronic coughing _____

Gagging, frequent need to clear throat _____

Sore throat, hoarseness, loss of voice _____

Swollen or discolored tongue, gums, lips_____

Canker sores _____

Total ________

SKIN

Acne _____

Hives, rashes, dry skin _____

Hair loss _____

Flushing, hot flashes _____

Excessive sweating _____

Total ________

HEART Irregular or skipped heartbeats _____

Rapid or pounding heartbeats _____

Chest pain _____

Total ________

LUNGS Chest congestion _____

Asthma, bronchitis _____

Shortness of breath _____

Difficulty breathing _____ Total ________

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DIGESTIVE TRACT Nausea, vomiting _____

Diarrhea _____

Constipation _____

Bloated feeling _____

Belching, passing gas _____

Heartburn _____

Intestinal/stomach pain _____

Anti-biotic use _____

Total ________

JOINT / MUSCLE Pain or aches in joint _____

Arthritis _____

Stiffness or limitation of movement _____

Pain or aches in muscles _____

Feeling of weakness or tiredness _____

Total ________

WEIGHT Binge eating / drinking _____

Cravings certain foods _____

Excessive weight _____

Compulsive eating _____

Water retention _____

Underweight _____

Total ________

ENGERY/ACTIVITY Fatigue, sluggishness _____

Apathy, lethargy _____

Hyperactivity _____

Restlessness _____

Total ________

MIND Poor memory _____

Confusion, poor comprehension _____

Poor concentration _____

Poor physical coordination _____

Difficulty in making decisions _____

Stuttering or stammering _____

Slurred speech _____

Learning disabilities _____

Total ________

EMOTIONS Mood swings _____

Anxiety, fear, nervousness _____

Anger, irritability, aggressiveness _____

Depression _____

Total ________

OTHER Frequent illness _____

Frequent or urgent urination _____

Bladder Leakage _____

Genital itch or discharge _____

Total ________

TOTAL, SECTION I: _____________

Please add any additional comments you feel would support your health care. (optional)

intake forms · naturopathic consult - client intake forms dr. keri brown, nd [email protected]...

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