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 · Web viewClient Information. Name Click or tap here to enter text. Address Click or tap here to...

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Client Information

Name Click or tap here to enter text.

Address Click or tap here to enter text.

City Click or tap here to enter text.State Click or tap here to enter text.Zip Code Click or tap here to enter text.

Phone (day) Click or tap here to enter text.Phone (cell) Click or tap here to enter text.

Phone (night) Click or tap here to enter text.

Email Click or tap here to enter text.

Referred by Click or tap here to enter text.

Statistics

Age Click or tap here to enter text.Birth Date Click or tap here to enter text.

Gender Click or tap here to enter text.

Height Click or tap here to enter text.

Blood Type Click or tap here to enter text.

Current Weight Click or tap here to enter text.Ideal Weight Click or tap here to enter text.

Weight One Year Ago Click or tap here to enter text.

Birth Weight (if known) Click or tap here to enter text.

Birth Order (please list ages of biological siblings) Click or tap here to enter text.

Family/Living Situation Click or tap here to enter text.

Children Click or tap here to enter text.

Occupation Click or tap here to enter text.

Exercise/Recreation Click or tap here to enter text.

History

1. Have you lived or traveled outside of the United States? If so, when and where? Click or tap here to enter text.

2. Have you or your family recently experienced any major life changes? If so, please comment: Click or tap here to enter text.

3. Have you experienced any major losses in life? If so, please comment: Click or tap here to enter text.

4. How much time have you had to take off from work or school in the last year?

☐ 0 to 2 days

☐ 3 to 14 days

☐ more than 15 days

Health Concerns

5. What are your main health concerns? (Describe in detail, including the severity of the symptoms): Click or tap here to enter text.

6. When did you first experience these concerns? Click or tap here to enter text.

7. How have you dealt with these concerns in the past? Click or tap here to enter text.

8. Have you experienced any success with these approaches? Click or tap here to enter text.

9. What other heath practitioners are you currently seeing? List name, specialty, and phone number. Click or tap here to enter text.

10. Please list the date and description of any surgical procedures you have had, including breast reduction or augmentation. Click or tap here to enter text.

11. How often did you take antibiotics in infancy/childhood? Click or tap here to enter text.

12. How often have you taken antibiotics as a teen? Click or tap here to enter text.

13. How often have you taken antibiotics as an adult? Click or tap here to enter text.

14. List any medicine you are currently taking: Click or tap here to enter text.

15. List all vitamins, minerals, herbs and nutritional supplements you are now taking: Click or tap here to enter text.

16. Have any other family members had similar problems? (Describe): Click or tap here to enter text.

Nutritional Status

17. Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptoms: Click or tap here to enter text.

18. Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so, please explain: Click or tap here to enter text.

19. Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain: Click or tap here to enter text.

20. Are there foods that you crave? If so, please explain: Click or tap here to enter text.

21. Describe your diet at the onset of your health concerns: Click or tap here to enter text.

22. Do you have any known food allergies or sensitivities? Click or tap here to enter text.

23. Which of the following foods do you consume regularly?

☐ soda☐ diet soda☐ refined sugar☐ alcohol☐ coffee

☐ fast food☐ gluten (wheat, barley, rye) ☐ dairy (milk, cheese, yogurt)

24. Are you currently on a special diet?

☐ autoimmune paleo (AIP)☐ paleo☐ SCD/GAPS☐ blood type☐ raw

☐ dairy restricted or dairy free☐ vegetarian☐ vegan☐ refined sugar free

☐ gluten free☐ Other (please describe): Click or tap here to enter text.

25. What percentage of your meals are home cooked?

☐10☐20☐30☐40☐50☐60☐70☐80☐90☐100

26. Is there anything else we should know about your current diet, history or relationship to food? Click or tap here to enter text.

Intestinal Status

27. Bowel Movement Frequency

☐ 1-3 times per day

☐ more than 3 times per day

☐ not regularly every day

28. Bowel Movement Consistency

☐soft and well-formed☐thin, long or narrow☐often float

☐small and hard☐difficult to pass☐loose but not watery

☐diarrhea☐alternating between hard and lose

29. Bowel Movement Color

☐medium brown☐very dark or black☐greenish☐variable

☐yellow, light brown☐chalky colored☐blood is visible☐greasy, slimy

30. Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc: Click or tap here to enter text.

31. Have you ever had food poisoning? If yes, please describe in detail, including 1) Where you were, 2) what did you treat it with and 3) if you feel like you fully recovered from it: Click or tap here to enter text.

Medical Status

32. Please identify any current or past conditions and add a date for when the condition appeared. In the space below each list, please briefly describe your symptoms, chosen treatment(s), and dates.

GASTROINTESTINAL

Past NowDate

☐☐__________ Gut Infections

☐☐__________ Dysbiosis

☐☐__________ Leaky Gut

☐☐__________ Food Allergies, intolerances or reactions

☐☐__________ Irritable Bowel Syndrome

☐☐__________ Crohn’s Disease

☐☐__________ Ulcerative Colitis

☐☐__________ Gastritis or Peptic Ulcer Disease

☐☐__________ GERD (reflux or heartburn)

☐☐__________ Celiac Disease

☐☐__________ Small Intestinal Bacterial Overgrowth (SIBO)

☐☐__________ Gall Stones

☐☐__________ Known absorption or assimilation issues

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and dates: Click or tap here to enter text.

CARDIOVASCULAR

PastNowDate

☐☐__________ Heart Attack

☐☐__________ Heart Disease

☐☐__________ Stroke

☐☐__________ Elevated Cholesterol

☐☐__________ Arrhythmia (irregular heartbeat)

☐☐__________ Hypertension (high blood pressure)

☐☐__________ Rheumatic Fever

☐☐__________ Mitral Valve Prolapse

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s), and dates: Click or tap here to enter text.

HORMONES/METABOLIC

PastNowDate

☐☐__________ Type 1 Diabetes

☐☐__________ Type 2 Diabetes

☐☐__________ Hypoglycemia

☐☐__________ Metabolic Syndrome

☐☐__________ Insulin Resistance or Pre-Diabetes

☐☐__________ Hypothyroidism (low thyroid)

☐☐__________ Hyperthyroidism (overactive thyroid)

☐☐__________ Hashimoto’s (autoimmune hypothyroid)

☐☐__________ Grave’s Disease (autoimmune hyperthyroid)

☐☐__________ Endocrine Problems

☐☐__________Polycystic Ovarian Syndrome (PCOS)

☐☐__________ Infertility

☐☐__________ Weight Gain

☐☐__________ Weight Loss

☐☐__________ Frequent Weight Fluctuations

☐☐__________ Eating Disorder

☐☐__________ Menopause Difficulties

☐☐__________ Hair Loss

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and dates: Click or tap here to enter text.

CANCER

Past NowDate

☐☐__________ Lung Cancer

☐☐__________ Breast Cancer

☐☐__________ Colon Cancer

☐☐__________ Ovarian Cancer

☐☐__________ Prostate Cancer

☐☐__________ Skin Cancer (Melanoma)

☐☐__________ Skin Cancer (Squamous, Basal)

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

GENITAL and URINARY SYSTEMS

PastNowDate

☐☐__________ Kidney Stones

☐☐__________ Gout

☐☐__________ Interstitial Cystitis

☐☐__________ Frequent Urinary Tract Infections (UTI)

☐☐__________ Erectile Dysfunction or Sexual Dysfunction

☐☐__________ Frequent Yeast Infections

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

MUSCULOSKELETAL/PAIN

Past NowDate

☐☐__________ Osteoarthritis

☐☐__________ Fibromyalgia

☐☐__________ Chronic Pain

☐☐__________ Sore muscles or joints, undiagnosed

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

IMMUNE/INFLAMMATORY

PastNowDate

☐☐__________ Chronic Fatigue Syndrome

☐☐__________ Rheumatoid Arthritis

☐☐__________ Lupus SLE

☐☐__________ Raynaud’s

☐☐__________ Psoriasis

☐☐__________ Mixed Connective Tissue Disease (MCTD)

☐☐__________ Poor Immune Function (frequent infections)

☐☐__________ Food allergies

☐☐__________ Environmental Allergies

☐☐__________ Multiple Chemical Sensitivities

☐☐__________ Latex Allergy

☐☐__________ Hepatitis

☐☐__________ Lyme (and co-infections)

☐☐__________ Chronic Infections (Epstein-Barr, Cytomegalo-virus, STD’s, etc.)

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

RESPIRATORY CONDITIONS

PastNowDate

☐☐__________ Asthma

☐☐__________ Chronic Sinusitis

☐☐__________ Bronchitis

☐☐__________ Emphysema

☐☐__________ Pneumonia

☐☐__________ Sleep Apnea

☐☐__________ Frequent or recurrent colds/flu

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

SKIN CONDITIONS

PastNowDate

☐☐__________ Eczema

☐☐__________ Psoriasis

☐☐__________ Dermatitis

☐☐__________ Hives

☐☐__________ Rash, undiagnosed

☐☐__________ Acne

☐☐__________ Skin Cancer (Melanoma)

☐☐__________ Skin Cancer (Squamous, Basal)

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

NEUROLIGIC/MOOD

Past NowDate

☐☐__________Depression

☐☐__________ Anxiety

☐☐__________ Bipolar Disorder

☐☐__________ Schizophrenia

☐☐__________ Headaches

☐☐__________ Migraines

☐☐__________ ADD/ADHD

☐☐__________ Autism

☐☐__________ Mild Cognitive Impairment

☐☐__________ Memory Problems

☐☐__________ Parkinson’s Disease

☐☐__________ Multiple Sclerosis

☐☐__________ ALS

☐☐__________ Seizures

☐☐__________ Dementia or Alzheimer’s

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

MISCELLANEOUS

Past NowDate

☐☐__________ Anemia

☐☐__________ Chicken Pox

☐☐__________ German Measles

☐☐__________ Measles

☐☐__________ Mononucleosis

☐☐__________ Mumps

☐☐__________ Sleep Apnea

☐☐__________ Whooping Cough

☐☐__________ Tuberculosis

☐☐__________ Known genetic variants (SNP’s, Polymorphisms, etc.)

☐☐__________ Other Click or tap here to enter text.

Please briefly describe your symptoms, chosen treatment(s) and date: Click or tap here to enter text.

33. Please check the frequency of the following:

Short term memory impairment☐ Yes☐ No☐ Sometimes

Shortened focus of attention and ability to concentrate☐ Yes☐ No☐ Sometimes

Coordination and balance problems☐ Yes☐ No☐ Sometimes

Problems with lack of inhibition☐ Yes☐ No☐ Sometimes

Poor organization abilities☐ Yes☐ No☐ Sometimes

Problems with time management (late or forget appointments)☐ Yes☐ No☐ Sometimes

Mood instability☐ Yes☐ No☐ Sometimes

Difficulty understanding speech and word finding☐ Yes☐ No☐ Sometimes

Brain fog, brain fatigue☐ Yes☐ No☐ Sometimes

Lower effectiveness at work, home or school☐ Yes☐ No☐ Sometimes

Judgement problems like leaving the stove on, etc.☐ Yes☐ No☐ Sometimes

Health Hazards

34. Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)? Click or tap here to enter text.

35. Do odors affect you? Click or tap here to enter text.

36. Are you or have you been exposed to second-hand smoke? Click or tap here to enter text.

Oral Health History

37. How long since you last visited the dentist? What was the reason for your visit? Click or tap here to enter text.

38. In the past 12 months has a dentist or hygienist talked to you about your oral health, blood sugar or other health concerns? (Please explain) Click or tap here to enter text.

39. What is your current oral and dental regimen? (Please note whether this regimen is once or twice daily or occasionally and what kind of toothpaste you use.) Click or tap here to enter text.

40. Do you have any mercury amalgams? (If so, were they removed? If so, how?) Click or tap here to enter text.

41. Do you have any concerns about your oral or dental health? Click or tap here to enter text.

42. Is there anything else about your current oral or dental health or health history that you’d like us to know? Click or tap here to enter text.

Lifestyle History

43. Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time. Click or tap here to enter text.

44. Have you used or abused alcohol, drugs, medications, tobacco or caffeine? Do you still? Click or tap here to enter text.

45. How do you handle stress? Click or tap here to enter text.

Sleep History

46. Are you satisfied with your sleep? Click or tap here to enter text.

47. Do you stay awake all day without dozing? Click or tap here to enter text.

48. Do you fall asleep in less than 30 minutes? Click or tap here to enter text.

49. Do you remain asleep throughout the night? If not, is there a timeframe that you tend to wake up regularly? Click or tap here to enter text.

50. Do you sleep between 6 and 8 hours per night? Click or tap here to enter text.

For Women Only

51. How old were you when you first got your period? Click or tap here to enter text.

52. How are/were your periods? Do/did you have PMS? Painful Periods? If so, explain. Click or tap here to enter text.

53. In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability? Click or tap here to enter text.

54. Have you experienced any yeast infections or urinary tract infections? Are they regular? Click or tap here to enter text.

55. Have you/do you still take birth control pills? If so, please list the length of time and type: Click or tap here to enter text.

56. Have you had any problems with conception or pregnancy? Click or tap here to enter text.

57. Are you taking any hormone replacement therapy (HRT) or hormonal supportive herbs? If so, please list length of time and type: Click or tap here to enter text.

Sexual History

58. Do you have any concerns or issues with your sexual functioning that you’d like to share with us (pain with intercourse, dryness, libido issues, erectile dysfunction)? Click or tap here to enter text.

Mental Health Status

59. How are your moods in general? Do you experience more anxiety, depression or anger than you would like? Click or tap here to enter text.

60. On a scale of 1 – 10, one being the worst and 10 being the best, describe your usual level of energy. Click or tap here to enter text.

61. At what point in your life did you feel best? Why? Click or tap here to enter text.

Other

62. Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no. Click or tap here to enter text.

63. Who in your family or on your health care team will be most supportive of you making dietary changes? Click or tap here to enter text.

64. Please describe any other information you think would be useful in helping to address your health concern(s): Click or tap here to enter text.

65. What are your health goals and aspirations? Click or tap here to enter text.

66. Though it may seem odd, please consider why you might want to achieve that for yourself: Click or tap here to enter text.

Michele Law, INHC

Inner Sage Healing Arts Center

1 Grove Street, Suite 103; Pittsford, NY 14534

(585) 383-8833

of 17/17
Client Information Name Click or tap here to enter text. Address Click or tap here to enter text. City Click or tap here to enter text. State Click or tap here to enter text. Zip Code Click or tap here to enter text. Phone (day) Click or tap here to enter text. Phone (cell) Click or tap here to enter text. Phone (night) Click or tap here to enter text. Email Click or tap here to enter text. Referred by Click or tap here to enter text. Statistics Age Click or tap here to enter text. Birth Date Click or tap here to enter text. Gender Click or tap here to enter text. Height Click or tap here to enter text. Blood Type Click or tap here to enter text. Current Weight Click or tap here to enter text. Ideal Weight Click or tap here to enter text. Weight One Year Ago Click or tap here to enter text. Birth Weight (if known) Click or tap here to enter text. Birth Order (please list ages of biological siblings) Click or tap here to enter text. Michele Law, INHC Inner Sage Healing Arts Center 1 Grove Street, Suite 103; Pittsford, NY 14534 (585) 383-8833
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