Female Symptom Assessment

Transcription

1 Female Symptom Assessment Name: Birthdate: Gender: _ Phone: _ General Health Assessment (Part 1) Please indicate how frequently you experience the following symptoms Never = 0% of the time Rarely = Lessthan 30% of the time Sometimes = About 50% of the time Often = More than 70% of the time according to these guidelines: Do you feel tired most of the time? Lifestyle-altering fatigue ONever ORarely OSometimes ooften Intestinal gas ONever ORarely OSometimes ooften Abdominal bloating ONever ORarely OSometimes ooften Sugar cravings Bread or beer cravings Constipation and/or diarrhea Irritability and/or moodiness Brain fog and/or poor memory Feeling faint, dizzy, or lightheaded Muscle or body aches Itching or burning sensation in rectum or vagina Lossof sexual desire White thrush or yellow fuzzy tongue Athlete's foot, ringworm, or jock itch Fingernail or toenail fungus Sensitivity to perfumes, insecticides, or other Chemical smells Weight gain and/or struggling to maintain a healthy weight ONever ORarely OSometimes ooften Think your weight is out of control

2 General Health Assessment (Part 2) Please indicate how frequently you've taken the following medications throughout your life. Antibiotics ONever ORarely OSometimes ooften Birth Control ONever ORarely OSometimes Ootten Steroids drugs (possibly for allergies, asthma, or injuries) ONever ORarely OSometimes Ootten Synthetic hormones (such as HRT or bioidentical) ONever ORarely OSometimes OOtten

3 Thyroid Function Assessment Please indicate to how jrequently you experience the jojjowing symptoms Never = 0%of the ti me Rarely = Lessthan 30%of the time Sometimes = About 50%of the time Often = More than 70%of the time and conditions according to these guidelines: Difficulty getting out of bed in the morning ONever ORarely OSometimes OOtten Need caffeine or other stimulants to get going ONever ORarely OSometimes OOtten Gain Weight easily Difficulty losing weight Dry skin Irregular menstrual cycles Mood swings Thinning hair Outer third of eyebrows missing or nothing Dry or brittle hair High cholesterol Low blood pressure ONever ORarely OSometimes OOtten Depression Yellow skin ONever ORarely OSometimes OOtten Do you have a family history of thyroid disease? OYes ONo

4 Stress Assessment Please indicate how frequently you experience the following situations according to these guidelines: Never = 0% of the time Rarely = Less than 30% of the time Sometimes = About 50% of the time Often = More than 70% of the time Close support network of family and friends Happy with your current job/profession Exercise regularly Eat 3 meals and 0-2 snacks per day Consume caffeine, sugar, and/or refined carbohydrates Take time off work to recharge your batteries Take a multivitamin/mineral Worry about money and finances Satisfaction with your life and its direction 8 hours of uninterrupted sleep at night Anxiety and/or panic attacks Think you're too stressed Suffer from allergies, arthritis, fibromyalgia, and/ or asthma Trouble falling asleep Feel exhausted after exercising Major life stressors such as death, divorce, etc. Catch colds and flu easily

5 Hormone Assessment Please indicate how frequently you experience the following situations according to these guidelines: Never = 0% of the time Rarely = Lessthan 30% of the time Sometimes = about 50% of the time Often = More than 70% of the time Vaginal dryness o Never o Rarely OSometimes o Often Mood swings o Never o Rarely OSometimes o Often Sagging skin o Never o Rarely OSometimes o Often Poor sleep quality o Never o Rarely OSometimes o Often Memory problems o Never o Rarely OSometimes o Often Night sweats o Never o Rarely OSometimes o Often Hot flashes o Never o Rarely OSometimes o Often Painful intercourse o Never o Rarely OSometimes o Often Bladder infections o Never o Rarely OSometimes o Often Low blood sugar o Never o Rarely OSometimes o Often Migraine/tension headaches o Never o Rarely OSometimes o Often Heavy blood flow o Never o Rarely OSometimes o Often Puffiness/bloating o Never o Rarely OSometimes o Often Anxiety o Never o Rarely OSometimes o Often Insomnia o Never o Rarely o Sometimes o Often Infertility o Never o Rarely OSometimes o Often M iscarriages o Never o Rarely OSometimes ooften PMS symptoms o Never o Rarely OSometimes o Often Painful or lumpy breast o Never o Rarely OSometimes o Often Endometriosis o Never o Rarely o Sometimes o Often Osteoporosis o Never o Rarely Osometimes o Often Water retention o Never o Rarely Osometimes o Often Unusual facial/arm/leg hair o Never ORarely OSometimes o Often Acne breakouts o Never ORarely OSometimes o Often Painful ovaries o Never ORarely OSometimes o Often Brown age spots o Never o Rarely osometimes o Often Inability to exercise o Never o Rarely OSometimes o Often

6 Toxic Burden Assessment (Part 1- Consumption) Please indicate how frequently you consume the following foods on a daily and/or weekly basis according to these guidelines: Never = 0% of the time Rarely = Lessthan 30% of the time Sometimes = About 50% of the time Often = More than 70%of the time Organic, pesticide-free produce ONever ORarely OSometimes ooften A wide variety of different vegetables colored fruits and Salads with dark leafy greens Flaxseeds and/or flaxseed oil Green juices or smoothies Organic, extra-virgin oils ONever ORarely OSometimes ooften Fresh green herbs ONever ORarely OSometimes ooften Coffee (including specialty) ONever ORarely OSometimes ooften Tobacco and nicotine (including e-cigarettes) Alcohol (beer, wine, hard liquor, etc.) Soda (regular and or diet) "Diet foods" sweetened with aspartame, Splenda, or saccharin Vegetables oil, canola oil, and/ or margarine Foods flavored with MSG (monosodium glutamate) Foods that are artificially colored Foods microwaved in plastic containers Fast foods Processed foods( from a box, bag, or can)

7 Toxic Burden Assessment (Part 2 - Supplementation) Please mark how frequently you use the following supplements or medications on a daily and/or weekly basis: Hormone and antibiotic-free whey protein ONever ORarely OSometimes ooften Probiotic and/ or prebiotic supplements Digestive enzymes Prescription or over the counter (OTC) drugs Healthy oil supplements ( like salmon, flaxseed, or evening primrose oil) Clean and 100% pure supplements (like the Solutions4 products that are sold in our office Toxic Burden Assessment (Part 3-Lifestyle and Habits) Please mark how frequently you do the following: Overeat Chew your food completely Experience lower bowel issues Exercise to induce a hard sweat Sit in a sauna Use a cell phone with a headset or hands free Live or work in an environment indoor air that recirculates the Use pesticides on your property Travel by plane Use a computer Live by someone who smokes Use household cleaners (such as bleach, etc.) Keep green plants in your house Filter your water Use air purifiers in your home Drink half your body weight in ounces of water each day

8 Frequency of Consumption Please mark how many of each item(s) you consume on a daily and weekly basis. Daily Weekly Soda 1:101:111:121:131:141:151:16 1:111:121:131:141:151:161:171:181:19 Brewed Coffee 1:10 1:111:12 [J3 [J4I:1S[J6 1:11 [J21:13 [J4[JS[J6[J7[JS[J9 Specialty Coffee [J0[J1[J2 [J3[J4[JS [J6 [J1[J2[J3[J4[JS[J6[J7[JS[J9 Chips I:IO[J1 1:12 1:131:141:15 1:16 1:11 1:12 [J3 1:141:1S [J61:17 [J81:19 Candy 1:101:11 [J2 1:131:14 1:151:16 1:11 1:121:131:141:15 1:161:17 [J81:19 Gum [JO [J1 [J2[J3 [J4[JS [J6 1:11 1:121:13 [J4[JS[J6[J7[JS[J9 Alcoholic Beverage [J0[J1[J2[J3[J4[JS[J6 [J1 1:121:13 1:14[JS 1:16 [J7 I:ISI:I9 Cigarettes [J01:l1[J21:l31:l4I:lSI:l6 [J11:l21:131:141:151:161:171:181:19 Energy Drinks 1:101:111:121:131:141:151:16 1:111:121:131:14I:1S[J6[J7[JS[J9 Protein Bars [J0[J1[J2[J3[J4[JS[J6 [J1 [J2 [J3[J4[JS[J6[J7[JS[J9 Bagels / Muffins / 1:l0[J1[J2[J31:l4I:lSI:l6 1:l1 1:121:13 [J41:lS [J61:l71:lS1:l9 Donuts / Twinkies Fast Food 1:I0[J1 1:12 1:131:14[JS 1:16 1:11 1:121:13 1:141:1S 1:161:17 I:ISI:I9