DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE
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1 1 NAME: DATE: Please score the items you experience on a scale of 0-4 [check the box, enter a number]: 0 (I do not experience this) 1 (This is a mild problem) 2 (This is a significant problem) 3 (This is a major problem) 4 (This is a severe problem) Medications: 1 Constipation Food sittting in stomach after meals Acid-stomach Gassiness Burping or belching Cramping Bloating Frequent coughing Bloody stools 2 Difficulty handling stress Poor sleep Exhaustion Scars which heal darkly Dizziness on standing Low blood pressure Salt craving 3 Over 50 years old Food sits in stomach, burping after meals, constipation, Celiac disease, gastric bypass White spots on arms, Chron s disease On birth control pills, stimulants, antidepressants, acid-blocking medicines (e.g. Prilosec, Pepsid, Tagamet, Nexium) Glucophage, Metformin Balance problems Weakness in any body part Autoimmune disease Vegetarian diet 4 Pregnancy Regular or binge alcohol consumption Food sits in stomach, burping after meals, constipation, Celiac disease, gastric bypass On anti-convulsant medication, Met formin, Glucopphage, Sulfasalazine, Triampterene, Methotrexate, barbiturates Anemia Weakness Headaches Reduced appetite Sore tongue Palpitations Forgetfulness
2 2 5 Kidney stones Carpal tunnel syndrome Antidepressant medications, stimulants, caffeine, birth control pills 6 Psychosis High cholesterol Dermatitis Skin: red, sensitive to sun, thickened Appetite loss Beefy red tongue Apathy Co-ordination problems Dementia TOTAL 7 Frequent or binge use of alcohol Diet high in sweets, carb s 8 Low intake of fish, green leafy vegetables Dry skin Dry hair Thyroid dysfunction Illnesses associated with inflammation (e.g. any it is, such as arthritis, bursitis, prostatitis etc) Cardiovascular disease High triglycerides 9 Emotional lability Post partum depression Impaired immunity, frequent colds/infections Recent growth spurt White spots on nails, Slow wound healing, Stretch marks Growth retardation Hair loss Decreased libido Trouble with memory or word finding Loss of appetite Celiac Disease (gluten sensitivitywheat/oats/rye/barley) Regular or binge alcohol use Altered taste Vegetarian diet TOTAL 10 African American (no score; just check) Indoor occupation or home bound Northern climate Use sun block Hypertension Muscle or bone pain Frequent infections or inflammatory diseases Over 60 (no score; just check) Obese
3 3 11 Chronic Stress Dizziness when you stand or bend Low Blood pressure Craving salty foods-pretzels, pickles Easy bruising Inability to handle even slight stresses Hypoglycemia: dizzy, irritable, or sleepy if you go without food for 4-5 hours; symptoms relieved by food Scars, elbows, nipples, that are unusually dark Slow healing of cuts Unstable body temperatures (hot or cold) 12 Weight gain around your abdomen and in the face and cheeks Stretch marks-not from weight loss Adult onset diabetes Craving sweets Trouble falling or staying asleep 13 Excessive dark male pattern hair growth Irregular or no periods Eastern European heritage 14 PMS - note symptoms: Cravings Breast tenderness Bloating Cramping Other: Infertility Irregular menstrual cycles How long? Short cycles Long cycles On birth control pills: How long? In menopause: How long? (no score; just check) Trouble with short term memory Trouble learning new things Vaginal dryness Loss of sex drive Hot flashes 15 Depressed mood Lack of energy Reduced sex drive Loss of morning erection, erection less strong, trouble maintaining erection Reduced muscle strength Memory problems Increased abdominal fat Fractures in recent years Low sperm count Thinning or loss of male hair pattern Change in voice Reduced concentration Loss of height Loss of pleasure Deterioration in work performance Falling asleep after dinner
4 4 16 Low energy Dry skin Hair falling out more than normal Muscle weakness: going up stairs, getting out of cars, opening jars Sensitivity to cold Constipation Irregular/heavy/light periods Hoarseness Puffiness under eyes Puffy legs Brittle nails Weight gain Snoring Slowness in thinking Problems with concentration Trouble falling asleep Outer third of eyebrows thin Low body temperature 17 Excess energy Oily skin Tremor Unexplained weight loss Rapid or pounding heartbeat Decreased need for sleep Eyes bulging High body temperature 18 High cholesterol High triglycerides Hypertension Abdominal weight/large waist Heart disease Inflammatory bowel disease (Chron s Disease) Frequent diarrhea Gluten sensitivity (Celiac disease) - itis diseases(e.g., arthritis, colitis, prostatitis, diverticulitis, thyroiditis, sinusitis etc. Auto-immune disease (lupus, pernicious anemia, rheumatoid arthritis, multiple sclerosis, etc) HIV Chronic infections (periodontal gum disease, sinusitis, Lyme disease, infected root canals, yeast infections etc) Brain fog Reduced short term memory Trouble finding words Feeling confused with simple tasks Learning disabilities Feel like lying in bed all day Fevers or chills Night sweats Muscle or joint aches and pains Feeling swollen all over Pain Gastrointestinal problems Zinc spots on nails Acne Recent growth spurt Unusual graying of hair Lots of sweets or breads or fats in diet Food allergies/sensitivities Raccoon Eyes Easy and prolonged blanching of skin after pressure or mottled/uneven skin color Flooding or wet basement Mold in home Allergies Diabetes Regular or binge alcohol use Many mercury fillings, eating lots of tuna fish
5 5 NOTES:
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1 NAME DATE Please score the items you experience on a scale of 0-4: 0 (I do not experience this) 1 (This is a mild problem) 2 (This is a significant problem) 3 (This is a major problem) 4 (This is a severe
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ABA Chiropractic Holistic Health Center Nutritional Assessment
ABA Chiropractic Holistic Health Center Nutritional Assessment Name: DOB: Age: Social Security # Marital Status: M D S W Employer Occupation: Address: City: Zip: Phone: Alternate phone: Today s date: Emergency
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
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Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP
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