Name *

First Name

Last Name

Date of First Visit *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone # (home)

(###)

###

####

Telephone # (cell)

(###)

###

####

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Average how many hours of Actual sleep?

5

6

7

8

9

10

Less

Do you sleep well?

Yes

No

Previously

Awaken when rested?

Yes

No

Previously

Have dreams?

Yes

No

Previously

Spend time outside?

Yes

No

Previously

Do you eat three meals a day?

Yes

No

Previously

Do you drink coffee?

Yes

No

Previously

Do you drink black or green tea?

Yes

No

Previously

Do you drink cola or other sodas?

Yes

No

Previously

Do you consume artificial colors?

Yes

No

Previously

Do you carry a cell phone or other wireless device on your person regularly?

Yes

No

Previously

Where do you carry your cell phone or other wireless device?

Check all that apply

Pocket

Bag

Case

Other

Use alcoholic beverages?

Yes

No

Previously

Do you use tobacco?

Yes

No

Previously

Smoked previously?

Yes

No

Previously

Use of chemical fertilizers, pesticides or herbicides at home/apt. complex?

Yes

No

Previously

Use a microwave? (select most accurate)

Household, Yard, Bodycare, Other

Always

Often

Sometimes

Rarely

Never

Poor concentration?

Review of systems: Mental/Emotional

Yes

No

Previously

Depression?

Review of systems: Mental/Emotional

Yes

No

Previously

Anxiety or nervousness?

Review of systems: Mental/Emotional

Yes

No

Previously

Low motivation?

Review of systems: Mental/Emotional

Yes

No

Previously

Memory problems?

Review of systems: Mental/Emotional

Yes

No

Previously

Hypothyroid?

Review of systems: Endocrine

Yes

No

Previously

Heat intolerance?

Review of systems: Endocrine

Yes

No

Previously

Cold intolerance?

Review of systems: Endocrine

Yes

No

Previously

Seasonal depression?

Review of systems: Endocrine

Yes

No

Previously

Fatigue?

Review of systems: Endocrine

Yes

No

Previously

Hypoglycemia?

Review of systems: Endocrine

Yes

No

Previously

Diabetes?

Review of systems: Endocrine

Yes

No

Previously

Excessive hunger?

Review of systems: Endocrine

Yes

No

Previously

Chronic Fatigue Syndrome?

Review of systems: Immune

Yes

No

Previously

Chronically swollen glands?

Review of systems: Immune

Yes

No

Previously

Reactions to vaccinations?

Review of systems: Immune

Yes

No

Previously

Chronic infections?

Review of systems: Immune

Yes

No

Previously

Slow wound healing?

Review of systems: Immune

Yes

No

Previously

Muscle weakness?

Review of systems: Neurological

Yes

No

Previously

Vertigo or dizziness?

Review of systems: Neurological

Yes

No

Previously

Numbness or tingling?

Review of systems: Neurological

Yes

No

Previously

Easily stressed?

Review of systems: Neurological

Yes

No

Previously

Strange tastes/smells?

Review of systems: Neurological

Yes

No

Previously

Easy bruising?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Deep leg pain in calves?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Varicose veins?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Anemia?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Cold hands?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Cold feet?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Rashes, eczema, psoriasis?

Review of systems: Skin

Yes

No

Previously

Acne/boils?

Review of systems: Skin

Yes

No

Previously

Headaches?

Review of systems: Head

Yes

No

Previously

Migraines?

Review of systems: Head

Yes

No

Previously

Head Injury?

Review of systems: Head

Yes

No

Previously

Impaired vision?

Review of systems: Eyes

Yes

No

Previously

Color blindness?

Review of systems: Eyes

Yes

No

Previously

Frequent colds?

Review of systems: Nose/Sinuses

Yes

No

Previously

Stuffiness?

Review of systems: Nose/Sinuses

Yes

No

Previously

Sinus infections?

Review of systems: Nose/Sinuses

Yes

No

Previously

Nose bleeds?

Review of systems: Nose/Sinuses

Yes

No

Previously

Hay fever/allergies?

Review of systems: Nose/Sinuses

Yes

No

Previously

Frequent sore throat?

Review of systems: Mouth/Throat

Yes

No

Previously

Teeth grinding?

Review of systems: Mouth/Throat

Yes

No

Previously

Dental cavities?

Review of systems: Mouth/Throat

Yes

No

Previously

Dental fillings?

Review of systems: Mouth/Throat

Yes

No

Previously

Swollen glands/lymph nodes?

Review of systems: Neck

Yes

No

Previously

Pain or stiffness?

Review of systems: Neck

Yes

No

Previously

Asthma?

Review of systems: Respiratory

Yes

No

Previously

Shortness of breath?

Review of systems: Respiratory

Yes

No

Previously

High blood pressure?

Review of systems: Cardiovascular

Yes

No

Previously

Low blood pressure?

Review of systems: Cardiovascular

Yes

No

Previously

Swelling in ankles?

Review of systems: Cardiovascular

Yes

No

Previously

Constipation?

Review of systems: Gastrointestinal

Yes

No

Previously

Diarrhea?

Review of systems: Gastrointestinal

Yes

No

Previously

Ulcers?

Review of systems: Gastrointestinal

Yes

No

Previously

Pain on urination?

Review of systems: Urinary

Yes

No

Previously

Frequent infections?

Option One

Option Two

Ovarian cysts?

Review of systems: Females

Yes

No

Previously

Endometriosis?

Review of systems: Females

Yes

No

Previously

Low sexual desire?

Review of systems: Females

Yes

No

Previously

Are cycles regular?

Review of systems: Females

Yes

No

Previously

Bleeding between cycles?

Review of systems: Females

Yes

No

Previously

Birth control?

Review of systems: Females

Yes

No

Previously

Joint pain/stiffness (please specify below)

Review of systems: Musculoskeletal

Yes

No

Previously

Left Hand (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Right Hand (fingers: 1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Left Foot (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Right Foot (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Appendages

Review of systems: Musculoskeletal

Left wrist

Right wrist

Left elbow

Right elbow

Left shoulder

Right shoulder

Left hip

Right hip

Left knee

Right knee

Left ankle

Right ankle

Left upper back

Right upper back

Left mid back

Right mid back

Left low back

Right low back

Broken bones?

Review of systems: Musculoskeletal

Yes

No

Previously

Muscle spasms or cramps?

Review of systems: Musculoskeletal

Yes

No

Previously

Arthritis?

Review of systems: Musculoskeletal

Yes

No

Previously

Muscular pain or weakness?

Review of systems: Musculoskeletal

Yes

No

Previously

Sciatica?

Review of systems: Musculoskeletal

Yes

No

Previously