Health Questionnaires 75 Harvard Way Reno, NV 895 Phone 775-9-44 Fax 775-9-8545 www.powerhealthreno.com info@chiroarts.com
Power Health Dear valued Patient, We greatly appreciate you taking the time to fill out the following paperwork. Following your examination, we collate the information from your history packet with your examination information into a medical report. We find it beneficial for these reports to be sent to your general practitioner, so that they are aware of any discoveries relative to your health condition made in this office. By signing below, you are acknowledging and allowing us to send this report to your general practitioner. Sincerely, Power Health Staff Name of General Practitioner: Patient Name (please print): Patient/Guardian Signature: Date:
Dear valued patient, We greatly appreciate you taking the time to fill out the following paperwork. This greatly assists us in taking an accurate history, and this paperwork will be reviewed in detail at your initial consultation. Thank you, Power Health Staff Name: Date Of Birth: Sex: PLEASE LIST YOUR CHIEF COMPLAINTS IN ORDER OF SEVERITY:.. MEDICATIONS:... 4. 5. 6. 7. 8. 9..... 4. 5. 6. 7. 8. 9..
SUPPLEMENTS:... 4. 5. 6. 7. 8. 9..... 4. 5. 6. 7. 8. 9.. MEDICATION AND FOOD ALLERGIES:... 4. 5. 6. 7. 8. 9.. PAST MEDICAL HISTORY: Please indicate if you have had any of the following illness in the past, and also please describe when the illness stopped. If the illness is still current, please mark that it is current. ILLNESS DATE OF ONSET DATE OF CESSATION/CURRENT Anemia Arthritis Alcoholism Cancer Chronic Fatigue
Crohns Disease Diabetes Dizziness Eczema Emphysema Epilepsy Gallstones Gout Heart Attack Hepatitis Hypertension Irritable Bowel Syndrome Kidney Stones Mononucleosis Pneumonia Pre-diabetes Peripheral Neuropathy Psoriasis Rheumatoid Arthritis Sinusitis Sleep Apnea Stroke Thyroid Disease Vertigo Other SURGERIES: Please indicate all of the surgeries you have had in the past and what date they occurred. Please try to remember all of the surgeries you have had, as we want to know about everything from tonsillectomies to appendectomies. SURGERY DATE 4
FAMILY HISTORY Other Uncles Aunts Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Children Sister(s) Brother(s) Mother Check Family Members that Apply Father (Place mark any health problem(s) your family has suffered with either now or in the past) Age (if still alive) Age at death (if deceased) Heart Attack Stroke Uterine Cancer Colon Cancer Breast Cancer Ovarian Cancer Prostate Cancer Skin Cancer ADD/ADHD ALS or other Motor Neuron Diseases Alzheimer s Anemia Anxiety Arthritis Asthma Autism Autoimmune Diseases (such as Lupus) Bipolar Disease Bladder disease Blood clotting problems Celiac disease Dementia Depression Diabetes Eczema Emphysema Environmental Sensitivities Epilepsy Flu Food Allergies, Sensitivities, Intolerances Genetic disorders Glaucoma Headache Heart Disease High Blood Pressure High Cholesterol 9 5
Other Uncles Aunts Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Children Sister(s) Brother(s) Mother Father Check Family Members that Apply Inflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing spondylitis) Inflammatory Bowel Disease Insomnia Irritable Bowel Syndrome Kidney disease Multiple Sclerosis Nervous breakdown Obesity Osteoporosis Other Parkinson s Pneumonia/Bronchitis Psoriasis Psychiatric disorders Schizophrenia Sleep Apnea Smoking addiction Stroke Substance abuse (such as alcoholism) Ulcers Any other family history we should know about? If yes, please comment: What is the attitude of those close to you about your illness? Supportive n-supportive ESTABLISHING HEALTH GOALS Personal Message Before we begin our journey together, I would like to discuss something very important that will have a major impact on your ability to recover and achieve maximum improvement. After many years in private practice, I have had the opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms it s about living a life of vibrant health. I ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality; a discussion of how you have lived your life up to this point and how you will live it in the future. Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want you to be honest with yourself and really dig deep inside yourself for the answers. 6
REVIEW OF SYSTEMS: Please check yes or no as to whether you are currently or experiencing the following symptoms: SYMPTOM Lose weight without trying Fevers Chills t hungry Ear infections Sinus infections Throat infections Double vision Blurred vision Shortness of breath Constipation Diarrhea Acid reflux Pain with urination Frequent urination Depression Anxiety Thoughts of harming yourself YES NO If you have dizziness and or vertigo, please fill out the questions below. If you do not have dizziness and vertigo, please skip these questions. 7
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If you have headaches or migraines, please complete the following questions. Are your headaches preceded by visual changes, nausea, or sound sensitivity? Do your headaches last for hours? Do your headaches last for days? Are your headaches provoked by getting a good nights sleep? Are your headaches provoked by driving in a car? Are your headaches provoked by eating a certain food? Are your headaches provoked or more severe around your time of menses? Are your headaches provoked by going from a sit to a stand? Are your headaches worse with bending forward? Do your headaches become worse with stress? Are your headaches relieved by any prescribed medications or OTC meds? Please list the medications if the answer is yes: - Do your headaches occur at the same time of the day? With your headaches, do you have any of the following symptoms? Nausea Vomiting Blurred vision Double vision Sparkles of light in your vision If yes, to the right or to the left Zig zag lines in your vision If yes, to the right or to the left Lack of vision Please describe: Light sensitivity Sensitivity to sound Numbness or tingling in an extremity or the face Weakness in an extremity or in the face Dizziness Vertigo (the walls are spinning, or you are spinning) Redness of an eye Watering of an eye Other symptoms: - 4 9
Health Questionnaire (NTAF) Name: Age: Sex: Date: * Please circle the appropriate number - on all questions below. as the least/never to as the most/always. SECTION A Is your memory noticeably declining? Are you having a hard time remembering names and phone numbers? Is your ability to focus noticeably declining? Has it become harder for you to learn things? How often do you have a hard time remembering your appointments? Is your temperament getting worse in general? Are you losing your attention span endurance? How often do you find yourself down or sad? How often do you fatigue when driving compared to the past? How often do you fatigue when reading compared to the past? How often do you walk into rooms and forget why? How often do you pick up your cell phone and forget why? SECTION B How high is your stress level? How often do you feel that you have something that must be done? Do you feel you never have time for yourself? How often do you feel you are not getting enough sleep or rest? Do you find it difficult to get regular exercise? Do you feel uncared for by the people in your life? Do you feel you are not accomplishing your life s purpose? Is sharing your problems with someone difficult for you? SECTION C SECTION C How often do you get irritable, shaky, or have lightheadedness between meals? How often do you feel energized after eating? How often do you have difficulty eating large meals in the morning? How often does your energy level drop in the afternoon? How often do you crave sugar and sweets in the afternoon? How often do you wake up in the middle of the night? How often do you have difficulty concentrating before eating? How often do you depend on coffee to keep yourself going? How often do you feel agitated, easily upset, and nervous between meals? SECTION C Do you get fatigued after meals? Do you crave sugar and sweets after meals? Do you feel you need stimulants such as coffee after meals? Do you have difficulty losing weight? How much larger is your waist girth compared to your hip girth? How often do you urinate? Have your thirst and appetite been increased? Do you have weight gain when under stress? Do you have difficulty falling asleep? SECTION - S Are you losing your pleasure in hobbies and interests? How often do you feel overwhelmed with ideas to manage? How often do you have feelings of inner rage (anger)? How often do you have feelings of paranoia? How often do you feel sad or down for no reason? How often do you feel like you are not enjoying life? How often do you feel you lack artistic appreciation? How often do you feel depressed in overcast weather? How much are you losing your enthusiasm for your favorite activities? How much are you losing enjoyment for your favorite foods? How much are you losing your enjoyment of friendships and relationships? How often do you have difficulty falling into deep restful sleep? How often do you have feelings of dependency on others? How often do you feel more susceptible to pain? How often do you have feelings of unprovoked anger? How much are you losing interest in life? SECTION - D How often do you have feelings of hopelessness? How often do you have self-destructive thoughts? How often do you have an inability to handle stress? How often do you have anger and aggression while under stress? How often do you feel you are not rested even after long hours of sleep? How often do you prefer to isolate yourself from others? How often do you have unexplained lack of concern for family and friends? How easily are you distracted from your tasks? How often do you have an inability to finish tasks? How often do you feel the need to consume caffeine to stay alert? How often do you feel your libido has been decreased? How often do you lose your temper for minor reasons? How often do you have feelings of worthlessness? SECTION - G How often do you feel anxious or panic for no reason? How often do you have feelings of dread or impending doom? How often do you feel knots in your stomach? How often do you have feelings of being overwhelmed for no reason? How often do you have feelings of guilt about everyday decisions? How often does your mind feel restless? How difficult is it to turn your mind off when you want to relax? How often do you have disorganized attention? How often do you worry about things you were not worried about before? How often do you have feelings of inner tension and inner excitability? SECTION 4 - ACH Do you feel your visual memory (shapes & images) is decreased? Do you feel your verbal memory is decreased? Do you have memory lapses? Has your creativity been decreased? Has your comprehension been diminished? Do you have difficulty calculating numbers? Do you have difficulty recognizing objects & faces? Do you feel like your opinion about yourself has changed? Are you experiencing excessive urination? Are you experiencing slower mental response?
Metabolic Assessment Formtm Name: Age: Sex: Date: PART I Please list your 5 major health concerns in order of importance:. 4.. 5.. PART II Please circle the appropriate number on all questions below. as the least/never to as the most/always. Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or fuzzy debris on tongue Pass large amount of foul-smelling gas More than bowel movements daily Use laxatives frequently Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swelling Frequent bloating and distention after eating Category III Intolerance to smells Intolerance to jewelry Intolerance to shampoo, lotion, detergents, etc Multiple smell and chemical sensitivities Constant skin outbreaks Category IV Excessive belching, burping, or bloating Gas immediately following a meal Offensive breath Difficult bowel movements Sense of fullness during and after meals Difficulty digesting proteins and meats; undigested food found in stools Category V Stomach pain, burning, or aching -4 hours after eating Use of antacids Feel hungry an hour or two after eating Heartburn when lying down or bending forward Temporary relief by using antacids, food, milk, or carbonated beverages Digestive problems subside with rest and relaxation Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine Category VI Difficulty digesting roughage and fiber Indigestion and fullness last -4 hours after eating Pain, tenderness, soreness on left side under rib cage Excessive passage of gas Nausea and/or vomiting Stool undigested, foul smelling, mucus like, greasy, or poorly formed Frequent loss of appetite 5 Datis Kharrazian. All Rights Reserved. SMGEMAF(5)Version Category VII Abdominal distention after consumption of fiber, starches, and sugar Abdominal distention after certain probiotic or natural supplements Decreased gastrointestinal motility, constipation Increased gastrointestinal motility, diarrhea Alternating constipation and diarrhea Suspicion of nutritional malabsorption Frequent use of antacid medication Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome? Category VIII Greasy or high-fat foods cause distress Lower bowel gas and/or bloating several hours after eating Bitter metallic taste in mouth, especially in the morning Burpy, fishy taste after consuming fish oils Unexplained itchy skin Yellowish cast to eyes Stool color alternates from clay colored to normal brown Reddened skin, especially palms Dry or flaky skin and/or hair History of gallbladder attacks or stones Have you had your gallbladder removed? Category IX Acne and unhealthy skin Excessive hair loss Overall sense of bloating Bodily swelling for no reason Hormone imbalances Weight gain Poor bowel function Excessively foul-smelling sweat Category X Crave sweets during the day Irritable if meals are missed Depend on coffee to keep going/get started Get light-headed if meals are missed Eating relieves fatigue Feel shaky, jittery, or have tremors Agitated, easily upset, nervous Poor memory, forgetful between meals Blurred vision Category XI Fatigue after meals Crave sweets during the day Eating sweets does not relieve cravings for sugar Must have sweets after meals Waist girth is equal or larger than hip girth Frequent urination Increased thirst and appetite Difficulty losing weight Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
Category XII 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 XIII Cannot fall asleep Perspire easily Under a high amount of stress Weight gain when under stress Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with little or no activity Category XIV Edema and swelling in ankles and wrists Muscle cramping Poor muscle endurance Frequent urination Frequent thirst Crave salt Abnormal sweating from minimal activity Alteration in bowel regularity Inability to hold breath for long periods Shallow, rapid breathing Category XV Tired/sluggish Feel cold hands, feet, all over Require excessive amounts of sleep to function properly Increase in weight even with low-calorie diet Gain weight easily Difficult, infrequent bowel movements Depression/lack of motivation Morning headaches that wear off as the day progresses Outer third of eyebrow thins Thinning of hair on scalp, face, or genitals, or excessive hair loss Dryness of skin and/or scalp Mental sluggishness Category XVI Heart palpitations Inward trembling Increased pulse even at rest Nervous and emotional Insomnia Category XVI (Cont.) Night sweats Difficulty gaining weight Category XVII (Males Only) Urination difficulty or dribbling Frequent urination Pain inside of legs or heels Feeling of incomplete bowel emptying Leg twitching at night Category XVIII (Males Only) Decreased libido Decreased number of spontaneous morning erections Decreased fullness of erections Difficulty maintaining morning erections Spells of mental fatigue Inability to concentrate Episodes of depression Muscle soreness Decreased physical stamina Unexplained weight gain Increase in fat distribution around chest and hips Sweating attacks More emotional than in the past Category XIX (Menstruating Females Only) Perimenopausal Alternating menstrual cycle lengths Extended menstrual cycle (greater than days) Shortened menstrual cycle (less than 4 days) Pain and cramping during periods Scanty blood flow Heavy blood flow Breast pain and swelling during menses Pelvic pain during menses Irritable and depressed during menses Acne Facial hair growth Hair loss/thinning Category XX (Menopausal Females Only) How many years have you been menopausal? Since menopause, do you ever have uterine bleeding? Hot flashes Mental fogginess Disinterest in sex Mood swings Depression Painful intercourse Shrinking breasts Facial hair growth Acne Increased vaginal pain, dryness, or itching years PART III How many alcoholic beverages do you consume per week? Rate your stress level on a scale of - during the average week: How many caffeinated beverages do you consume per day? How many times do you eat fish per week? How many times do you eat out per week? How many times do you work out per week? How many times do you eat raw nuts or seeds per week? List the three worst foods you eat during the average week: List the three healthiest foods you eat during the average week: PART IV Please list any medications you currently take and for what conditions: Please list any natural supplements you currently take and for what conditions: 5 Datis Kharrazian. All Rights Reserved. SMGEMAF(5)Version
Brain Health and Nutrition Assessment Form (BHNAF) Name: Age: Sex: Date: Please circle the appropriate number on all questions below. as the least/never to as the most/always. SECTION SECTION 5 Low brain endurance for focus and concentration Dry and unhealthy skin Cold hands and feet Dandruff or a flaky scalp Must exercise or drink coffee to improve brain function Poor nail health Consumption of processed foods that are bagged or boxed Fungal growth on toenails Consumption of fried foods Must wear socks at night Difficulty consuming raw nuts or seeds Nail beds are white instead of pink Difficulty consuming fish (not fried) The tip of the nose is cold Difficulty consuming olive oil, avocados, flax seed oil, or natural fats SECTION SECTION 6 Irritable, nervous, shaky, or light-headed between meals Difficulty digesting foods Feel energized after meals Constipation or inconsistent bowel movements Difficulty eating large meals in the morning Increased bloating or gas Energy level drops in the afternoon Abdominal distention after meals Crave sugar and sweets in the afternoon Difficulty digesting protein-rich foods Wake up in the middle of the night Difficulty digesting starch-rich foods Difficulty concentrating before eating Difficulty digesting fatty or greasy foods Depend on coffee to keep going Difficulty swallowing supplements or large bites of food Abnormal gag reflex or SECTION SECTION 7 Fatigue after meals Brain fog (unclear thoughts or concentration) or Sugar and sweet cravings after meals Pain and inflammation or Need for a stimulant, such as coffee, after meals ticeable variations in mental speed or Difficulty losing weight Brain fatigue after meals Increased frequency of urination Difficulty falling asleep Brain fatigue after exposure to chemicals, scents, or pollutants Increased appetite Brain fatigue when the body is inflamed SECTION 8 SECTION 4 Always have projects and things that need to be done Grain consumption leads to tiredness Never have time for yourself t getting enough sleep or rest Grain consumption makes it difficult to focus and concentrate Difficulty getting regular exercise Feel better when bread and grains are avoided Feel that you are not accomplishing your life s purpose Grain consumption causes the development of any symptoms A % gluten-free diet or Datis Kharrazian. All Rights Reserved. SMGEBHNAF4(8) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
Brain Health and Nutrition Assessment Form (BHNAF) Please circle the appropriate number on all questions below. as the least/never to as the most/always. SECTION 9 SECTION A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease or Family members who have been diagnosed with an autoimmune disease or Family members who have been diagnosed with celiac disease or gluten sensitivity or Changes in brain function with stress, poor sleep, or immune activation SECTION A decrease in visual memory (shapes and images) or 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 SECTION A loss of pleasure in hobbies and interests A decrease in mental alertness Feel overwhelmed with ideas to manage A decrease in mental speed Feelings of inner rage or unprovoked anger A decrease in concentration quality Feelings of paranoia Slow cognitive processing Feelings of sadness for no reason Impaired mental performance A loss of enjoyment in life An increase in the ability to be distracted A lack of artistic appreciation or Feelings of sadness in overcast weather Need coffee or caffeine sources to improve mental function A loss of enthusiasm for favorite activities A loss of enjoyment in favorite foods A loss of enjoyment in friendships and relationships Inability to fall into deep, restful sleep Feelings of dependency on others Feelings of susceptibility to pain SECTION SECTION 4 Feelings of worthlessness Feelings of nervousness or panic for no reason Feelings of hopelessness Feelings of dread Self-destructive thoughts Feelings of a knot in your stomach Inability to handle stress Feelings of being overwhelmed for no reason Anger and aggression while under stress Feelings of guilt about everyday decisions Feelings of tiredness, even after many hours of sleep A restless mind A desire to isolate yourself from others An inability to turn off the mind when relaxing An unexplained lack of concern for family and friends Disorganized attention An inability to finish tasks Worry over things never thought about before Feelings of anger for minor reasons Feelings of inner tension and inner excitability Datis Kharrazian. All Rights Reserved. SMGEBHNAF4(8) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition. 4
Brain Function Assessment Form (BFAF) Name: Age: Sex: Date: Please circle the appropriate number on all questions below. as the least/never to as the most/always. SECTION A decrease in attention span Mental fatigue Difficulty learning new things Difficulty staying focused and concentrating for extended periods of time Experiencing fatigue when reading sooner than in the past Experiencing fatigue when driving sooner than in the past Need for caffeine to stay mentally alert Overall brain function impairs your daily life SECTION Twitching or tremor in your hands and legs when resting Handwriting has gotten smaller and more crowded together A loss of smell to foods Difficulty sleeping or fitful sleep Stiffness in shoulders and hips that goes away when you start to move Constipation Voice has become softer Facial expression that is serious or angry Episodes of dizziness or light-headedness upon standing A hunched over posture when getting up and walking SECTION 4 Reduced function in overall hearing Difficulty understanding language with background or scatter noise Ringing or buzzing in the ear Difficulty comprehending language without perfect pronunciation Difficulty recognizing familiar faces Changes in comprehending the meaning of sentences, written or spoken Difficulty with verbal memory and finding words Difficulty remembering events Difficulty recalling previously learned facts and names Inability to comprehend familiar words when read Difficulty spelling familiar words Monotone, unemotional speech Difficulty understanding the emotions of others when they speak (nonverbal cues) Disinterest in music and a lack of appreciation for melodies Difficulty with long-term memory Memory impairment when doing the basic activities of daily living Difficulty with directions and visual memory ticeable differences in energy levels throughout the day SECTION Memory loss that impacts daily activities Difficulty planning, problem solving, or working with numbers Difficulty completing daily tasks Confusion about dates, the passage of time, or place Difficulty understanding visual images and spatial relationships (addresses and locations) Difficulty finding words when speaking Misplacement of things and inability to retrace steps Poor judgment and bad decisions Disinterest in hobbies, social activities, or work Personality or mood changes SECTION 5 Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach for objects Difficulty comprehending written text Floaters or halos in your visual field Dullness of colors in your visual field during different times of the day Difficulty discriminating similar shades of color Datis Kharrazian. All Rights Reserved. SMGEBFAF(8) Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition. 5
Brain Function Assessment Form (BFAF) Please circle the appropriate number on all questions below. as the least/never to as the most/always. SECTION 6 SECTION 9 Difficulty with detailed hand coordination A decrease in movement speed Difficulty with making decisions Difficulty initiating movement Difficulty with suppressing socially inappropriate thoughts Stiffness in your muscles (not joints) Socially inappropriate behavior A stooped posture when walking Decisions made based on desires, regardless of the consequences Cramping of your hand when writing Difficulty planning and organizing daily events Difficulty motivating yourself to start and finish tasks A loss of attention and concentration SECTION SECTION 7 Hypersensitivities to touch or pain Abnormal body movements (such as twitching legs) Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall Desires to flinch, clear your throat, or perform some type of movement Frequently bumping into the wall or objects Constant nervousness and a restless mind Difficulty with right-left discrimination Compulsive behaviors Handwriting has become sloppier Increased tightness and tone in specific muscles Difficulty with basic math calculations Difficulty finding words for written or verbal communication Difficulty recognizing symbols, words, or letters SECTION 8 SECTION Difficulty swallowing supplements or large bites of food Bowel motility and movements slow Bloating after meals Dry eyes or dry mouth A racing heart A flutter in the chest or an abnormal heart rhythm Bowel or bladder incontinence, resulting in staining your underwear Datis Kharrazian. All Rights Reserved. SMGEBFAF(8) Difficulty with balance, or balance that is noticeably worse on one side A need to hold the handrail or watch each step carefully when going down stairs Episodes of dizziness Nausea, car sickness, or seasickness A quick impact after consuming alcohol A slight hand shake when reaching for something Back muscles that tire quickly when standing or walking Chronic neck or back muscle tightness Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition. 6
ESTABLISHING HEALTH GOALS Personal Message Before we begin our journey together, I would like to discuss something very important that will have a major impact on your ability to recover and achieve maximum improvement. After many years in private practice, I have had the opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms it s about living a life of vibrant health. I ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality; a discussion of how you have lived your life up to this point and how you will live it in the future. Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want you to be honest with yourself and really dig deep inside yourself for the answers. What do you hope to achieve in your visit with us? If you had a magic wand and could erase three problems, what would they be?... Have you made the decision to change? To do what it takes to get well? I have read something interesting: The definition of insanity is to keep doing the same thing and expecting different results. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination. Most people I ask tell me they re made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having reasons to actually do it. When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness. So now I ask: What have you have been unable to do as a result of your present symptoms. Please be specific. (Use extra pages if necessary) 7
What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give examples. What are you most concerned with regarding your problem? Where do you picture yourself being in the next - years if this problem is not taken care of? Please be specific. What specific improvements in your health would you consider a successful outcome in your case? How would you feel if you spent more time, energy, and money under our care and had no improvements in your case? What do you plan to do once you are feeling better. Please be specific. (Use extra pages if necessary) Are there any other health goals you want to achieve? 8
DENTAL HISTORY Have you had sore gums (gingivitis) often over the years? Has ringing in the ears (tinnitus) been present? Have TMJ (temporal mandibular joint) problems been a concern? Do you often have a 'metallic' taste in your mouth? Do you have a lot of bad breath (halitosis) or white tongue (thrush)? Have you worn or do you presently wear braces? Do you have problems chewing? Do you floss regularly? Did your mother have dental fillings prior to giving birth to you? Did you have fillings as a child? Age Describe Dental Work Health Problems following dental work? (describe) 9
RELEVANT DIET HISTORY List the foods you like: List the foods you dislike and why: List any food allergies: List any foods cravings: List number of meals daily and when: List number of meals over the weekend and when: List snacks and when: Percentage of meals: Baked: % Boiled: % Fresh: % Frozen: % Home Prepared: % Eaten Out: %
Liquid Consumption Water Milk Soda Diet Soda Beer Wine Liquor Amount Frequency Previous dietary programs (low sodium, low fat, Atkins, gluten-free, etc): Weight loss/gain: DIET LOG Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner:
Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner: Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner: Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner:
Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner: Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner: Date: Breakfast: Snack: Lunch: Snack: Dinner: After Dinner: