FUNCTIONAL HEALTH ASSESSMENT

FUNCTIONAL HEALTH ASSESSMENT Name Age Sex M F Date Address Blood Type: A B AB O (+) (-) Unsure? City State Zip Email Phone Work Phone Mobile Fax Date of Birth Ht Wt Wt at 20 yr Marital Status Children Education Occupation Hobbies Chemically Sensitive? Emergency Contact Phone Known Allergies Chief Complaints How did you hear of us or who referred you Present Medications (prescription and non-prescription Vitamin/Mineral Supplements LIFE STYLE HISTORY (PLEASE) CIRCLE THE ONE WHICH FITS BEST) Health: VERY GOOD MODERATE POOR VERY POOR Health: VERY GOOD MODERATE POOR VERY POOR Fat/Cholesterol Intake: NONE SOME REGULAR OFTEN Exercise (please also indicate number of times per week): Type NONE SOME REGULAR OFTEN Stress Levels: NONE SOME REGULAR OFTEN Alcohol Intake (if you drink please indicate number of drinks per week): Smoking (if you smoke please indicate number of packs per day): (beer, wine, liquor) # years: # years:

Do you experience or have: No Yes Date of Onset Do you experience or have: No Yes Date of Onset MEN Lack of energy Sleeplessness/restless Exercise (what) Balding Weight gain/loss Self examine Lethargic during day Memory loss Low sex drive Impotent Premature ejaculation Sexual disfunction Testicular pain Urinary tract infections Yeast infections Urethral discharge Poor muscle mass Enlarged breast/nipple Low sperm count Sexually active Low AM temperatures Scars (where) Smoke (how much) Alcohol (how much) Chronic pain WOMEN Lack of energy Sleeplessness/restless Exercise (what) Thinning hair/hair loss Weight gain/loss Get sick easily Lethargic during day Memory loss Low sex drive Vaginal dryness/burning Yeast/urinary tract infections Sexual disfunction Discomfort/pain during sex Fibrocystic breasts Uncomfortably cold often Uncomfortably warm often Regular/irregular menstruation Sexually active Pre/Post menopause Date of last period PMS Pregnant # of children & type of delivery Scars (where) Chronic pain

Do you experience or have: No Yes Date of Onset Do you experience or have: No Yes Date of Onset HEAD Headaches (and type) Blurry vision (and when) Ringing in the ears (type) Dizziness (and when) Sinus problems (and when) Itchy scalp/dandruff Brittle hair/hair loss DENTAL TMJ pain or popping jaw Amalgam how many? If removed, when and by whom? Tooth extractions (any problems?) Caps (gold or ceramic) Root canals - how many? Missing teeth Bridge work/braces Gum disease NECK Stiffness/pain/spasms Limited range of motion Injuries Dull/sharp pain Any past surgery BACK Muscle spasms Dull/sharp pain Limited range of motion Injuries/surgeries Chiropractic therapy Disc problems Deformities Osteoporosis LOWER EXTREMITIES Cold toes or feet Joint pain (where) Numbness (where) Numbing/tingling pain Arthritis condition UPPER EXTREMITIES Joint pain Numbness (where) Arthritis CHEST Dull/sharp pain Tightness Angina Other heart related problems GI TRACT Heartburn (when) Diarrhea/constipation Hemorrhoids (type) Food sensitivities Blood in stool BMs (per day or week) Parasites SKIN Psoriasis Dermatitis Cosmetic surgery Blotches/redness Acne Moles/warts Aging too fast?

Do you experience or have: No Yes Date of Onset Do you experience or have: No Yes Date of Onset NAILS Ridged/spotted/split Brittle/slow growth Lifestyle International travel (where) Participate in sports (type) Fungus EYES Blood-shot/dry/itchy Use recreational drugs (list) Pain/burning/yellow Glaucoma Cataracts NOSE Dry/burn/bleed Congested Snoring THROAT/TONGUE Hoarse/dry throat Phlegm Coating on tongue Marking on tongue Hetero/Homosexual (circle one) Past sexual abuse Ever exposed to toxic chemicals? Water Know family history? Raised (where) Deformities Auto-Immune disorder (what) Are you in a relationship? Rate from I-10 (10 being best) Typical breakfast: Split in tongue Chronic bad breath Metallic taste EARS Typical lunch: Excessive wax Ringing Itching Ear tubes (ever and when) Typical dinner: Injuries Hearing aid needed THYROID Thyroid medications Snacks: Surgery

FEMALE PATIENTS ONLY Name Date Address Blood Type: A B AB O (+) (-) Unsure? D.O.B. Primary Physician Specialist PERSONAL HEALTH HISTORY Last Mammogram Implants? Explain Last Pap smear Type [ ] Thin Prep [ ] Wet Mount Findings MENSTRUAL CYCLE INFORMATION Last menstrual cycle [ ] Pre-Menstrual [ ] Post-Menstrual [ ] Peri-Menopausal [ ] Pregnant Date of hysterectomy (if applicable) [ ] Complete [ ] Partial, explain Any recent injuries or accidents involving breast or reproductive organs [ ] No [ ] Yes Explain HISTORY Any history of breast disease or cysts? [ ] No [ ] Yes, explain Any history of thyroid dysfunction? [ ] No [ ] Yes, explain Any history of cancer of any type? [ ] No [ ] Yes, explain Any history of Fibrocystic Breast? [ ] No [ ] Yes, explain Any bone spurs now or in the past? [ ] No [ ] Yes (explain): Breast tender or swollen 2 weeks before period? [ ] No [ ] Yes, explain OTHER: Differential Diagnosis Pulse Tongue Treatment Strategy

PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AS POSSIBLE; YOUR ANSWERS WILL DETERMINE HOW WEMAY PROCEED WITH YOUR CARE 2. When was the last time you felt the best physically, emotionally, and psychologically? [ ] 3-6 months ago [ ] 1 year ago [ ] 5 years ago [ ] 10 years ago [ ] 20 years ago Actual Date 3. Diet: Please describe your diet (indicate all applicable choices): [ ] Protein - High/Low [ ] Special diet, list [ ] Fat - High/Low [ ] Use sugar or sweeteners, list [ ] Carbs - High/Low [ ] Drink juices [ ] # meals per day [ ] Crave salty foods [ ] Eat red meat [ ] Eat grains [ ] Crave sweets/yeast foods [ ] Cholesterol (High/Med /Low) [ ] Snacks, list [ ] Coffee /Tea intake a day [ ] Soft drinks / week [ ] Been told to reduce fat 4. Please chart energy and sleep levels with 10 being the best: ENERGY SLEEP 5. Have you at any time in you life taken broad-spectrum antibiotics (or any antibiotics) for respiratory, urinary, ear or other infections? [ ] No [ ] Yes Have you taken any antibiotics for skin, acne, or anything else? [ ] No [ ] Yes, explain 6. Place in box who in the family had the following: (Mother)-M, (Father)-F, (Sibling)-S, (Grandmother)-GM, etc... Allergies Cancer Diabetes Osteoarthritis Osteoporosis Asthma Multiple Sclerosis Muscular Dystrophy Mental Illness Auto-Immune Disorder Rheumatoid Arthritis Heart Disease Psoriasis Drug Abuse Stroke ADD Fatigue Hepatitis Thyroid Disease Candida Epstein Barr Virus STDs Surgeries

CHRONOLOGY OF YOUR HEALTH EVENTS: Please list, starting with the last time you felt well, any events, such as surgery, high stress events, dental work, child birth, accidents, hormonal changes, travel, immunizations, etc... Please take time to remember all events. DATE EVENT

SYMPTOM CHECKLIST Patient Name Patient Weight Lab Test Date Date Diet Started Checklist Date Medical Diagnosis (if any) SYMPTOM POINT SCALE: Use the point scale to rate your symptoms past 30 days. 0 = never or almost never have the symptom 1 = occasionally have it, effect is not severe 2 = occasionally have it, effect is severe 3 = frequently have it, effect is not severe 4 = frequently have it, effect is severe DIGESTIVE TRACT Nausea & vomiting Diarrhea Constipation Bloated feeling Stomach pains or cramps Heart burn Blood and/or mucous in stools EARS Itchy ears Ear aches, ear infections Drainage from ear Ringing in ears Hearing loss Reddening of ears EMOTIONS Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Argumentative Frustrated, cries easily Depression ENERGY Apathy, lethargy Fatigue Hyperactivity Restlessness Poor physical condition Stuttering or stammering Slurred speech EYES Watery or itchy eyes Red, swollen or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision HEAD Headaches Faintness Dizziness Insomnia, sleep disorder HEART Irregular or skipped heartbeat Rapid or pounding heart Chest pain JOINTS & MUSCLES Pains or aches in joints Arthritis Stiffness or limited movement Pain or aches in muscles Feeling of weakness or tiredness Swollen tender joints Growing pains in legs LUNGS Chest congestion Asthma, bronchitis Shortness of breath Persistent cough Wheezing MIND Poor memory Underachiever Poor/short attention span Confusion Easily distracted Learning disabilities MOUTH & THROAT Chronic coughing Gagging, often clearing throat Sore throat, hoarse, loss of voice Swollen or discolored tongue, lips Canker sores Itching on roof of mouth NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucous formation SKIN Acne Itching Hives, rash, dry skin Hair loss WEIGHT Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention OTHER Frequent illness Frequent or urgent urination Genital itch or discharge Anal itching GRAND TOTAL

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