Adult Comprehensive Assessment

Transcription

1 Adult Comprehensive Assessment Doreen Bell Schiffert 121 Sully s Trail, Suite 7 Pittsford, New York health@doreenbellschiffert.com Name Address Date City State Zip Code Phone Age Height Weight Birth Date Married/Single Occupation Children Who referred you for your appointment today? Would you like to receive a natural heath ? Yes No Please list your three major health concerns in order of importance Medications: Supplements: Allergies: I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food, whole food supplements, vitamins, minerals, herbs and other natural modalities as a guide to general good health. I fully understand that I am not being counseled by a medical doctor and that I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visits as an agent for federal, state or local agencies or on a mission of entrapment or investigation. Doreen Bell Schiffert does not diagnose or treat disease or illness. The services performed here are restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve diagnosis, treatment or prescribing remedies for disease. Appointment cancellations require a 24-hour notice or the full session fee will be charged. Signature Date

2 Please circle the appropriate number (or circle yes or no or write number) for all questions below regarding your current health status. 0 as the least/never to 3 as the most/always. Category One High blood pressure Low blood pressure Pain in heart Poor circulation Swelling in ankles Category Two Bach ache Arthritis/bursitis Stiffness General soreness Category Three Acne Bruises Dry skin Itchy skin Rashes Category Four Lung pain Difficulty breathing Congestion Shortness of breath Category Five Asthma Seasonal allergies Sinus infection Sore throat Throat clearing Category Six Excessive urination Water retention Burning urination Kidney stones Lower back pain Dark circles under eyes Itchy eyes/ears Pain down legs Category Seven Feeling that bowels do not empty completely Alternating constipation and diarrhea Diarrhea Constipation Hard, dry or fuzzy stool Coated tongue or fuzzy debris on tongue Gas Use of laxatives Number of bowel movements daily Category Eight Increasing number of food reactions Unpredictable food reactions Aches, pains, swelling throughout body Unpredictable abdominal swelling Frequent bloating or distension after eating Abdominal intolerance to sugar and starches Category Nine Intolerance to smells Intolerance to jewelry Intolerance to shampoo, lotions, detergents, etc Multiple smell and chemical sensitivities Skin outbreaks Category Ten Excessive belching, burping or bloating Gas immediately following a meal Bad breath Difficult bowel movements Difficulty digesting fruits and vegetables Undigested food in stool Stomach pain, burning or aching after eating Use of antacids Feel hungry an hour or two after eating Heartburn when laying down or bending forward Digestive problems subside with rest and relaxation Heartburn due to certain foods Category Eleven Roughage and fiber cause constipation Indigestion and fullness last 2-4 hours after eating Pain, tenderness, soreness on left side under rib cage Excessive gas Nausea and/or vomiting Stool is foul smelling or poorly formed Difficulty losing weight Category Twelve Greasy or high-fat foods cause distress Gas and/or bloating after eating Bitter metallic taste in mouth Unexplained itchy skin Yellowish cast to eyes Clay colored stool Reddened skin, especially palms Dry or flaky skin and/or hair History of gallbladder attacks or stones Have you had your gallbladder removed?

3 Category Thirteen Acne and unhealthy skin Excessive hair loss Overall sense of bloating Bodily swelling for no reason Hormone imbalances Weight gain Poor bowel function Excessive foul-smelling sweat Menstrual or menopause issues Category Fourteen Cannot stay asleep Crave salt Slow starter in the morning Afternoon fatigue Dizziness when standing up quickly Afternoon headaches Headaches with exertion or stress Weak nails Category Fifteen Cannot fall asleep Perspire easily Under high amounts of stress Weight gain when under stress Wake up tired even after 6 or more hours of sleep Excessive perspiration with little or no activity Category Sixteen Edema and swelling in wrists and ankles Muscle cramping Poor muscular endurance Frequent urination Frequent thirst Crave salt Abnormal swelling from minimal activity Shallow rapid breathing Category Seventeen Tired/sluggish Feel cold hands, feet, all over Require excessive amounts of sleep to function Gain weight easily Difficult, infrequent bowel movements Depression/lack of motivation Morning headaches that wear off Outer third of eyebrow thin Thinning of hair or excessive hair loss Dryness of skin and/or scalp Mental sluggishness Category Eighteen Heart palpitations Inward trembling Increased pulse even at rest Nervous and emotional Insomnia Night sweats Difficulty gaining weight Category Nineteen Low brain endurance for focus and concentration Cold hands and feet Must exercise or drink coffee to improve brain function Poor nail health Fungal growth on toenails Must wear socks at night Nail beds are white instead of pink The tip of nose is cold Category Twenty Irritable, nervous, shaky or lightheaded between meals Feel energized after meals Difficulty eating large meals in morning Crave sugars and sweets in afternoon Wake up in middle of the night Difficulty concentrating before eating Depend on coffee to keep going Category Twenty-One Fatigue after meals Sugar and sweet cravings after meals Need for stimulant, such as coffee, after meals Difficulty losing weight Increased frequency of urination Difficulty falling asleep Increased appetite Waist girth equal to or larger than hip girth Category Twenty-Two Always have projects and things to be done Never heave time for yourself Not getting enough sleep or rest Difficulty getting regular exercise Feeling that you are not accomplishing your life s purpose Category Twenty-Three Dry and unhealthy skin Dandruff or a flaky scalp Consumption of processed foods (bagged or boxed) Consumption of fried foods Consumption of raw nuts or seeds Consumption of fish (not fried) Consumption of olive oil, flaxseed oil or natural fats Category Twenty-Four Difficulty digesting foods Constipation or inconsistent bowel movements Bloating Difficulty digesting protein-rich foods Difficulty digesting starch-rich foods Difficulty digesting fatty or greasy foods Abnormal gag reflex Category Twenty-Five Brain fog (unclear thoughts or concentration) Pain and inflammation Noticeable variations in mental speed Brain fatigue after meals Brain fatigue after exposure to chemicals, scents or pollutants

4 Category Twenty-Six Grain consumption leads to tiredness Grain consumption makes it difficult to focus and concentrate Feel better when breads and grains are avoided Eat a gluten free diet A diagnosis of celiac disease, gluten sensitivity, hypothyroidism or an autoimmune disease Y /N Family members have been diagnosed with autoimmune, hypothyroidism or gluten sensitivity Changes in brain function with stress or poor sleep Category Twenty-Seven Loss in pleasure in hobbies and interests Feel overwhelmed with ideas to manage Feelings of inner rage or unprovoked anger Feelings or paranoia Feelings of sadness for no reason A loss of enjoyment of life Feelings of sadness in overcast weather A loss of enthusiasm for favorite activities A loss of enjoyment in friendships or relationships Inability to fall into a deep and restful sleep Category Twenty-Eight Feelings of worthlessness Feelings of hopelessness Self-destructive thoughts Inability to handle stress Anger and aggression while under stress Feelings of tiredness, even after many hours of sleep A desire to isolate yourself from others An unexpected lack of concern for friends and family An inability to finish tasks Feelings of anger for minor reasons Category Twenty-Nine A decrease in visual memory (shapes and images) A decrease in verbal memory Occurrence of memory lapses A decrease in creativity A decrease in comprehension Difficulty calculating numbers Difficulty recognizing objects and faces A change in opinion about yourself Slow mental recall Category Thirty A decrease in mental speed A decrease in concentration quality Slow cognitive processing Impaired mental performance Easily distracted Need coffee or caffeine to improve mental function Feelings of panic or nervousness for no reason Feelings of dread Feelings of a knot in your stomach Feelings of being overwhelmed for no reason Feelings of guilt about everyday decisions A restless mind An inability to turn off the mind when relaxing Disorganized attention Worry about things that you never thought about before Feelings of inner tension and inner excitability Category Thirty-Two (Females Only) Painful intercourse Yeast infections Hot flashes Breast pain Vaginal itching/discharge Headaches Migraines Facial hair growth Vaginal dryness/pain Mood swings Painful periods/cramps Thyroid issues Cysts Anemia Endometrious Fibroids Genital herpes Breast lump Removed? Hysterectomy Date Menstruating Length of cycle: Menopause Date started: Category Thirty-Three (Males Only) Urination difficulty or dribbling Frequent urination Pain inside of legs or heels Feeling of incomplete bowel emptying Leg twitching at night Decreased libido Spells of mental fatigue Episodes of depression Muscle soreness Decreased physical stamina Unexplained weight gain Increased fat distribution around chest and hips Sweating attacks More emotional than in the past Category Thirty-One

5 Regular Dietary Habits How much water do you consume each day? How many caffeinated beverages do you consume per day? How many alcoholic beverages do you consume each week? Do you smoke? If yes, how much do you smoke each day? How many times do you eat out each week? List the three healthiest foods you eat each week List the three unhealthiest foods you eat each week Do you now or have you ever been on a restricted diet? If yes, please describe the restricted diet, when you did it and for how long? Regular Physical Activity Please write the type of physical activity that you do weekly, the number of times per week and the average duration. Activity Times per Week Duration Health History List all the major health problems you have had in the past five years (surgeries, hospitalizations, etc.). Health Problem Year Please mark any significant family health problems(s) listed below. diabetes thyroid problems heart problems cancer mental illness stroke obesity gout asthma autoimmune disorders (celiacs, Hashimoto s, RA, ANA, etc.) Please indicate the approximate date and describe the nature of any experiences (physical or emotional) that may be deemed traumatic (divorce, loss of relationship, loss of job, change of residence, injury [especially head injury], death). Physical or Emotional Trauma Year

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