Chronic Condition New Patient Form

    Metabolic Assessment Form

    PART I
    Please list your 5 major health concerns in order of importance:

    1)
    2)
    3)
    4)
    5)

    PART II
    Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

    Category I

    0123     Feeling that bowels do not empty completely
    0123     Lower abdominal pain relieved by passing stool or gas
    0123     Alternating constipation and diarrhea
    0123     Diarrhea
    0123     Constipation
    0123     Hard, dry, or small stool
    0123     Coated tongue or "fuzzy" debris on tongue
    0123     Pass large amount of foul-smelling gas
    0123     More than 3 bowel movements daily
    0123     Use laxatives frequently

    Category II

    0123     Increasing frequency of food reactions
    0123     Unpredictable food reactions
    0123     Aches, pains, and swelling throughout the body
    0123     Unpredictable abdominal swelling
    0123     Frequent bloating and distention after eating
    0123     Abdominal intolerance to sugars and starches

    Category III

    0123     Intolerance to smells
    0123     Intolerance to jewelry
    0123     Intolerance to shampoo, lotion, detergents, etc.
    0123     Multiple smell and chemical sensitivities
    0123     Constant skin outbreaks

    Category IV

    0123     Excessive belching, burping, or bloating
    0123     Gas immediately following a meal
    0123     Offensive breath
    0123     Difficult bowel movement
    0123     Sense of fullness during and after meals
    0123     Difficulty digesting fruits and vegetables; undigested food found in stools

    Category V

    0123     Stomach pain, burning, or aching 1-4 hours after eating
    0123     Use antacids
    0123     Feel hungry an hour or two after eating
    0123     Heartburn when lying down or bending forward
    0123     Temporary relief by using antacids, food, milk, or carbonated beverages
    0123     Digestive problems subside with rest and relaxation
    0123     Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

    Category VI

    0123     Roughage and fiber cause constipation
    0123     Indigestion and fullness last 2-4 hours after eating
    0123     Pain, tenderness, soreness on left side under rib cage
    0123     Excessive passage of gas
    0123     Nausea and/or vomiting
    0123     Stool undigested, foul smelling, mucous like, greasy, or poorly formed
    0123     Frequent urination
    0123     Increased thirst and appetite

    Category VII

    0123     Greasy or high-fat foods cause distress
    0123     Lower bowel gas and/or bloating several hours after eating
    0123     Bitter metallic taste in mouth, especially in the morning
    0123     Burpy, fishy taste after consuming fish oils
    0123     Difficulty losing weight
    0123     Unexplained itchy skin
    0123     Yellowish cast to eyes
    0123     Stool color alternates from clay colored to normal brown
    0123     Reddened skin, especially palms
    0123     Dry or flaky skin and/or hair
    0123     History of gallbladder attacks or stones
    YesNo     Have you had your gallbladder removed?

    Category VIII

    0123     Acne and unhealthy skin
    0123     Excessive hair loss
    0123     Overall sense of bloating
    0123     Bodily swelling for no reason
    0123     Hormone imbalances
    0123     Weight gain
    0123     Poor bowel function
    0123     Excessively foul-smelling sweat

    Category IX

    0123     Crave sweets during the day
    0123     Irritable if meals are missed
    0123     Depend on coffee to keep going/get started
    0123     Get light-headed if meals are missed
    0123     Eating relieves fatigue
    0123     Feel shaky, jittery, or have tremors
    0123     Agitated, easily upset, nervous
    0123     Poor memory/forgetful
    0123     Blurred vision

    Category X

    0123     Fatigue after meals
    0123     Crave sweets during the day
    0123     Eating sweets does not relieve cravings for sugar
    0123     Must have sweets after meals
    0123     Waist girth is equal or larger than hip girth
    0123     Frequent urination
    0123     Increased thirst and appetite
    0123     Difficulty losing weight

    Category XI

    0123     Cannot stay asleep
    0123     Crave salt
    0123     Slow starter in the morning
    0123     Afternoon fatigue
    0123     Dizziness when standing up quickly
    0123     Afternoon headaches
    0123     Headaches with exertion or stress
    0123     Weak nails
    *** Make sure you complete the questions in the right column. ***

    Category XII

    0123     Cannot fall asleep
    0123     Perspire easily
    0123     Under high amount of stress
    0123     Weight gain when under stress
    0123     Wake up tired even after 6 or more hours of sleep
    0123     Excessive perspiration or perspiration with little or no activity

    Category XIII

    0123     Edema and swelling in ankles and wrists
    0123     Muscle cramping
    0123     Poor muscle endurance
    0123     Frequent urination
    0123     Frequent thirst
    0123     Crave salt
    0123     Abnormal sweating from minimal activity
    0123     Alteration in bowel regularity
    0123     Inability to hold breath for long periods
    0123     Shallow, rapid breathing

    Category XIV

    0123     Tired/sluggish
    0123     Feel cold?hands, feet, all over
    0123     Require excessive amounts of sleep to function properly
    0123     Increase in weight even with low-calorie diet
    0123     Gain weight easily
    0123     Difficult, infrequent bowel movements
    0123     Depression/lack of motivation
    0123     Morning headaches that wear off as the day progresses
    0123     Outer third of eyebrow thins
    0123     Thinning of hair on scalp, face, or genitals, or excessive hair loss
    0123     Dryness of skin and/or scalp
    0123     Mental sluggishness

    Category XV

    0123     Heart palpitations
    0123     Inward trembling
    0123     Increased pulse even at rest
    0123     Nervous and emotional
    0123     Insomnia
    0123     Night sweats
    0123     Difficulty gaining weight

    Category XVI

    0123     Diminished sex drive
    0123     Menstrual disorders or lack of menstruation
    0123     Increased ability to eat sugars without symptoms

    Category XVII

    0123     Increased sex drive
    0123     Tolerance to sugars reduced
    0123     "Splitting" - type headaches

    Sex & Status * required

    Category XVIII (Males Only)

    0123     Urination difficulty or dribbling
    0123     Frequent urination
    0123     Pain inside of legs or heels
    0123     Feeling of incomplete bowel emptying
    0123     Leg twitching at night

    Category XIX (Males Only)

    0123     Decreased libido
    0123     Decreased number of spontaneous morning erections
    0123     Decreased fullness of erections
    0123     Difficulty maintaining morning erections
    0123     Spells of mental fatigue
    0123     Inability to concentrate
    0123     Episodes of depression
    0123     Muscle soreness
    0123     Decreased physical stamina
    0123     Unexplained weight gain
    0123     Increase in fat distribution around chest and hips
    0123     Sweating attacks
    0123     More emotional than in the past

    Category XX (Menstruating Females Only)

    YesNo     Perimenopausal
    YesNo     Alternating menstrual cycle lengths
    YesNo     Extended menstrual cycle (greater than 32 days)
    YesNo     Shortened menstrual cycle (less than 24 days)
    0123     Pain and cramping during periods
    0123     Scanty blood flow
    0123     Heavy blood flow
    0123     Breast pain and swelling during menses
    0123     Pelvic pain during menses
    0123     Irritable and depressed during menses
    0123     Acne
    0123     Facial hair growth
    0123     Hair loss/thinning

    Category XXI (Menopausal Females Only)

        How many years have you been menopausal?
    YesNo     Since menopause, do you ever have uterine bleeding?
    0123     Hot flashes
    0123     Mental fogginess
    0123     Disinterest in sex
    0123     Mood swings
    0123     Depression
    0123     Painful intercourse
    0123     Shrinking breasts
    0123     Facial hair growth
    0123     Acne
    0123     Increased vaginal pain, dryness, or itching

    PART III

    How many alcoholic beverages do you consume per week?
    Rate your stress level on a scale of 1-10 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:

    Patient Information

    Please fill out the following form in as much detail as possible. All your health information is kept confidential.

    Name:
    Address:
    City:
    State:
    ZIP:
    Date of Birth:
    Sex:
    # Kids:
    Height:
    Weight:
    Status:
    SingleMarriedPartneredDivorcedWidowedMinor
    Occupation:
    Employer/School:
    Cell Phone:
    Email:
    Preferred contact method:
    Cell PhoneWork PhoneEmail
    Spouse/Partner's Name:
    Who Referred You?

    In case of emergency please contact:

    Name:
    Relationship:
    Home Phone:
    Other Phone:

    Patient Condition

    What is your major complaint? (be as specific as possible)
    When did you condition/symptoms/pain first appear? (specific date, days ago, weeks, ago, etc.)
    Is this condition getting progressively worse? YesNoConstantComes & goes
    When is it worse? MorningAfternoonEveningChanges time of day
    Does it interfere with:
    WorkSleepDaily RoutinesRecreationOther (fill in text box below)
    Other description:
    How long has it been since you really felt good?
    Other doctors seen for this condition: MDDCDODDSOther (fill in text box below)
    Other description:
    Does the condition/symptom/pain radiate? YesNo
    If yes, where and how frequently:
    How long/often does the radiation occur/last?
    Do you have: NumbnessTinglingWeaknessNone of these
    Describe above selections:
    List your body part condition/symptoms/pain & rating # on the scale below 0 (none) - 10 (severe):
    Body part:
    Severity:
    Body part:
    Severity:
    Body part:
    Severity:
    Type of pain:
    SharpDullThrobbingTinglingShootingBurningAchingNumbness
    What activities or positions aggravate your condition?
    BendingCoughingGetting up/downDrivingLiftingLying downSneezingStandingStraining at stoolTurning headTwistingWalking
    What activities or positions relieve your condition:
    HeatLying downIceMedicationSittingMassageSittingStandingStretchingExercise
    Have you ever had this condition before? YesNo
    If yes, when?
    Were you treated for this condition or a similar one before? YesNo
    If yes, when/by whom?

    Health History

    Do you have any allergies? (food, contact, environmental)
    List any prescribed medications, over the counter medications, vitamins, herbs and supplements:
    When was your last:
    Physical exam:
    Blood/lab work:
    X-ray study:
    Injuries/Surgeries you’ve had and when:
    Have you had or do you have any of the following conditions or diseases?
    Ankylosing spondulitisAnxietyArthritisAsthmaBleeding disorderBlurred visionBowel/Bladder problemsBuzzing in earCancerCarpal tunnelCeliac disease (gluten)Chest painsChronic fatigueCold hands or feetColitis/discerticulitisCompression fracturesConnective tissue issuesCOPD (bronchitis/emphy)DepressionDiabetesDigestive/bowel problemsDizziness or vertigoFibromyalgiaFusions (spinal, joint)GoutHear diseaseHepatitis (A, B, C, etc.)HerpesHigh blood pressureHip replacementHIV/AIDSKidney diseaseKnee surgeryLiver diseaseMarfan syndromeMultiple sclerosisOsteoporosis/peniaParkinson’s diseaseRotator cuff problemSTI/STDShoulder surgerySpinal surgeryStroke/TIAThyroid problemsTuberculosis
    Other:
    Other:
    Are there any conditions that run in your family? YesNo
    If yes, what & who?

    Personal and Social Health History

    Are you currently pregnant, or do you think you may be pregnant? YesNo
    If yes, how many weeks?
    How many hours per week do you typically work/attend school?
    <2020304040+
    What are your typical duties and postures (sitting, standing, lifting, etc.)?
    Do you exercise? YesNo
    If yes, how often and what type?
    How would you rate your eating habits?
    ExcellentPretty GoodCould be betterNeeds Improvement
    How well do you sleep?
    ExcellentPretty GoodRestlessCan't sleepWake up often
    How many hours of sleep do you get daily?
    Do you feel rested in the morning? YesNo
    How is your energy overall?
    Full powerOKLowSporadic/Generally fatiguedI depend on caffeine for energy
    How do you feel your immune system is working?
    StrongOKLow