Intake Questionnaire – Female

Personal Information

Legal First Name

Legal Last Name

Preferred First Name

Middle Name

Street Address

Unit

City

State/Province

Postal Code

Home Phone

Mobile Phone

Email Address

Date of Birth

Gender

Pronouns

Relationship Status

Occupation

Hours Per Week

If Other

When and from whom did you last receive medical or health care?

GP Contact Details

Legal First Name

Last Name

Street Address

Unit

City

State/Province

Postal Code

Home Phone

Mobile Phone

Email Address

Emergency Contact

Name

Relationship

Phone Number

If "Other", please specify

Current Health Concerns

Please list current and ongoing health concerns in order or priority.

Example: "Post Nasal Drip - mild - Elimination Diet - Very effective".

Describe Problem	Severity	Prior Treatment/Approach	Effectiveness
	MildModerateSevere		FairGoodExcellent
	MildModerateSevere		FairGoodExcellent
	MildModerateSevere		FairGoodExcellent
	MildModerateSevere		FairGoodExcellent
	MildModerateSevere		FairGoodExcellent

Allergies

Name of Medication/Supplement/Food	Reaction

Lifestyle Review

Sleep

How many hours of sleep do you get each night on average?

Do you have problems falling asleep?
YesNo

Do you have problems staying asleep?
YesNo

Do you have problems with insomnia?
YesNo

Do you snore?
YesNo

Do you feel rested upon awakening?
YesNo

Do you use sleeping aids?
YesNo

Exercise

Current exercise program:

Activity	Type	# of Times Per Week	Time/Duration (Minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (e.g. gold)
Other

Do you feel motivated to exercise?
YesA littleNo

Are there any problems that limit exercise?
YesNo

Do you feel unusually fatigued or sore after exercise?
YesNo

Nutrition

If Other, please explain

Do you have sensitivities to certain foods?
YesNo

If you selected "Other food substances", please list food and symptoms here

Are there any foods that you crave or binge on?
YesNo

Do you eat 3 meals a day?
YesNo

Does skipping a meal greatly affect you?
YesNo

How many meals do you eat out per week?
0–11–33–5>5 meals per week

Diet

Please record what you eat in a typical day:

Breakfast

Lunch

Dinner

Snacks

Fluids

How many servings do you eat in a typical week of these foods:

Fruits (not juice)	Vegetables (not including white potatoes)
Legumes (beans, peas, etc.)	Red meat
Fish	Dairy/Alternatives
Nuts & Seeds	Fats & Oils
Cans of soda (regular or diet)	Sweets (candy, cookies, cake, ice cream, etc.)

Do you drink caffeinated beverages?
YesNo

If yes, check amounts (cups/cans per day)

	1	2-4	>4
Coffee	1	2-4	>4
Tea	1	2-4	>4
Caffeinated sodas—regular or diet (cans per day)	1	2-4	>4

Do you have reactions to caffiene?
YesNo

When you drink caffeine do you feel:
Irritable or weirdAches or pains

Smoking

Do you smoke currently?
YesNo

If you smoke currently:
Packs per day	Number of years

Have you attempted to quit?
YesNo

If you smoked previously
Packs per day	Number of years

Are you regularly exposed to second-hand smoke?
YesNo

Alcohol

How many alcoholic beverages do you drink in a week?
(1 drink = 1 small glass of wine, 1 can of beer, or 1.5 oz spirits)

Previous alcohol intake
NoneMildModerateHigh

Have you ever had a problem with alcohol?
YesNo

Have you ever thought about getting help to control or stop your drinking?
YesNo

Other Substances

Are you currently using any recreational drugs?
YesNo

Have you ever used IV or inhaled recreational drugs?
YesNo

Stress

Do you feel you have an excessive amount of stress in your life?
YesNo

Do you feel you can easily handle the stress in your life?
YesNo

How much stress do each of the following cause on a daily basis?
(Rate each on a scale of 1–10, 10 = most stress)

	1	2	2	4	5	6	7	8	9	10
Work	1	2	3	4	5	6	7	8	9	10
Family	1	2	3	4	5	6	7	8	9	10
Social	1	2	3	4	5	6	7	8	9	10
Finances	1	2	3	4	5	6	7	8	9	10
Finances	1	2	3	4	5	6	7	8	9	10
Health	1	2	3	4	5	6	7	8	9	10

Do you use relaxation techniques?
YesNo

If you chose "Other", which other relaxation technique do you use?

Have you ever sought counseling?
YesNo

Are you currently in therapy?
YesNo

Have you ever been abused, a victim of crime, or experienced significant trauma?
YesNo

What are your hobbies or leisure activities?

Relationships

With whom do you live?
(Include children, parents, relatives, friends, pets)

Current occupation

Previous occupations

Do you have resources for emotional support?
YesNo

If you checked "Other", which other resource for emotional support do you have?

Do you have a religious or spiritual practice?
YesNo

How well have things been going for you?
(Mark on a scale of 1-10 - 1=poorly, 10=very well -, or n/a if not applicable)

	N/A	1	2	2	4	5	6	7	8	9	10
Overall	N/A	1	2	3	4	5	6	7	8	9	10
At School	N/A	1	2	3	4	5	6	7	8	9	10
In Your Job	N/A	1	2	3	4	5	6	7	8	9	10
With Close Friends	N/A	1	2	3	4	5	6	7	8	9	10
With Sex	N/A	1	2	3	4	5	6	7	8	9	10
With Your Attitude	N/A	1	2	3	4	5	6	7	8	9	10
With Your Boyfriend/Girlfriend	N/A	1	2	3	4	5	6	7	8	9	10
With Your Children	N/A	1	2	3	4	5	6	7	8	9	10
With Your Parents	N/A	1	2	3	4	5	6	7	8	9	10
With Your Spouse	N/A	1	2	3	4	5	6	7	8	9	10

History

Patient's Birth/Childhood History

Were you born:
TermPrematureDon't know

Were there any pregnancy or birth complications?
YesNo

How were you fed as an infant?
Breast-fedBottle-fedDon't know

If you were bottle fed:

	How Long?	Type Of Formula
Bottle-Fed

Age of introduction of:
(ignore if you don't know)

Solid Food

Wheat

Dairy

As a child, were there any foods that were avoided because they gave you symptoms?
YesNo

Did you eat a lot of sugar or candy as a child?
YesNo

Dental History

Do you currently have any of the following?

Concern	Check if Yes
Tooth pain	Yes
Bleeding gums	Yes
Gingivitis	Yes
Problems with chewing	Yes
Other dental concerns	Yes

If you checked "Other dental concerns", please explain:

Have you had any mercury fillings removed?
YesNo

How many fillings did you have as a kid?

Do you brush regularly?
YesNo

Do you floss regularly?
YesNo

Environmental/Detoxification History

Do any of these significantly affect you?
Cigarette SmokePerfume/ColognesAuto Exhaust FumesOther

If you checked "Other", please explain:

Have you had significant exposure to any harmful
chemicals?
YesNo

Do you have any pets or farm animals?
YesNo

If you do have pets or farm animals, do they live
InsideOutsideBoth inside & outside

Women's History

Obstetric History
(Check box and provide number if applicable)

	Applicable	Number
Pregnancies	Applicable
Miscarriages	Applicable
Abortions	Applicable
Living children	Applicable
Vaginal deliveries	Applicable
Cesarean sections	Applicable
Term births	Applicable
Premature births	Applicable

Birth weight of

	Birth Weight in lbs.
Largest Baby
Smallest Baby

Did you develop any problems in or after pregnancy?
(Check all that apply)

Toxemia (high blood pressure)DiabetesPost-partum depresionIssues with breast-feedingOther

If you checked "Other", please explain

Menstrual History
Age at first period	Date of last menstrual period
Length of cycle	Time between cycles

Cramping?
YesNo

Pain?
YesNo

Have you ever had premenstrual problems (bloating,
breast tenderness, irritability, etc.)?
YesNo

Do you have other problems with your period (heavy,
irregular, spotting, skipping, etc.)?
YesNo

Use of hormonal birth control
(Add another option if your birth control option is not listed.)

	Applicable	How Many Years?
Birth control pill	Applicable
Patch	Applicable
Implant	Applicable
Nuva Ring	Applicable
Mirena Coil	Applicable
Other	Applicable

If you checked "Other", please explain:

Any problems with hormonal birth control?
YesNo

Are you in menopause?
YesNo

Was it surgical menopause?
YesNo

Are you on hormone replacement therapy (HRT)?
YesNo

If you checked "Sexually transmitted disease", please describe.

Gynecological Screening/Procedures
(If applicable, provide date)

	Date	Normal	Abnormal
Last Pap / Smear Test		Normal	Abnormal
Last Mammogram		Normal	Abnormal

Last bone density test

	Date	High	Low	Within Normal Range
Bone density		High	Low	Within Normal Range

Other gynecological tests or procedures
(list type and dates)

Other Tests/Procedures

Test/Procedure	Date	Result

Family History

Age of family members
(MGM=maternal grandmother, MGF=maternal grandfather, PGM=paternal grandmother,
PGF=paternal grandfather)

	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
If still alive
Age at death

Check family members that have/had any of the following
(MGM=maternal grandmother, MGF=maternal grandfather, PGM=paternal grandmother, PGF=paternal grandfather, IBS=irritable bowel syndrome)

	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Cancer	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Heart disease	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Hypertension	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Obesity	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Diabetes	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Stroke	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Autoimmune disease	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Arthritis	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Thyroid problems	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Seizures / epilepsy	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Psychiatric disorders	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Anxiety	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Depression	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Asthma	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Allergies	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
ADHD	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Autism	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
IBS	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Dementia	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Substance abuse	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Genetic disorders	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other
Other	Mother	Father	Brother(s)	Sister(s)	Child	Child	Child	Child	MGM	MGF	PGM	PGF	Other

If you checked "Other" with any of your family members, please explain

Medical History

Illnesses/Conditions

Check Yes = a condition you currently have, check Past = a condition you've had
in the past.

Gastrointestinal

	Yes	Past
Irritable bowel syndrome (IBS)	Yes	Past
GERD (reflux)	Yes	Past
Crohn's disease / ulcerative colitis	Yes	Past
Peptic ulcer disease	Yes	Past
Celiac disease	Yes	Past
Gallstones	Yes	Past

Respiratory

	Yes	Past
Bronchitis	Yes	Past
Asthma	Yes	Past
Emphysema	Yes	Past
Pneumonia	Yes	Past
Sinusitis	Yes	Past
Sleep apnea	Yes	Past

Urinary/Genital

	Yes	Past
Kidney stones	Yes	Past
Gout	Yes	Past
Interstitial cystitis	Yes	Past
Frequent yeast infections	Yes	Past
Frequent urinary tract infections	Yes	Past
Sexual dysfunction	Yes	Past
Sexually transmitted diseases	Yes	Past

Endocrine/Metabolic

	Yes	Past
Diabetes	Yes	Past
Hypothyroidism (low thyroid)	Yes	Past
Hyperthyroidism (overactive thyroid)	Yes	Past
Polycystic Ovarian Syndrome	Yes	Past
Infertility	Yes	Past
Metabolic syndrome/insulin resistance	Yes	Past
Eating disorder	Yes	Past
Hypoglycemia	Yes	Past

Inflammatory/Immune

	Yes	Past
Rheumatoid arthritis	Yes	Past
Chronic fatigue syndrome	Yes	Past
Food allergies	Yes	Past
Environmental allergies	Yes	Past
Multiple chemical sensitivities	Yes	Past
Autoimmune disease	Yes	Past
Mononucleosis	Yes	Past
Hepatitis	Yes	Past

Musculoskeletal

	Yes	Past
Fibromyalgia	Yes	Past
Osteoarthritis	Yes	Past
Chronic pain	Yes	Past

Skin

	Yes	Past
Eczema	Yes	Past
Psoriasis	Yes	Past
Acne	Yes	Past
Skin cancer	Yes	Past

Cardiovascular

	Yes	Past
Angina	Yes	Past
Heart attack	Yes	Past
Heart failure	Yes	Past
Hypertension (high blood pressure)	Yes	Past
Stroke	Yes	Past
High blood fats (cholesterol, triglycerides)	Yes	Past
Rheumatic fever	Yes	Past
Arrhythmia (irregular heart rate)	Yes	Past
Murmur	Yes	Past
Mitral valve prolapse	Yes	Past

Neurologic/Emotional

	Yes	Past
Epilepsy/Seizures	Yes	Past
ADD/ADHD	Yes	Past
Headaches	Yes	Past
Migraines	Yes	Past
Depression	Yes	Past
Anxiety	Yes	Past
Autism	Yes	Past
Multiple sclerosis	Yes	Past
Parkinson's disease	Yes	Past
Dementia	Yes	Past

Cancer

	Yes	Past
Lung	Yes	Past
Breast	Yes	Past
Colon	Yes	Past
Ovarian	Yes	Past
Prostate	Yes	Past
Skin	Yes	Past

Diagnostic Studies

	Date	Comments
Bone density
CT scan
Colonoscopy
Cardiac stress test
EKG
MRI
Upper endoscopy
Upper GI series
Chest X-rays
Barium enema

Injuries

	Date	Comments
Broken bone(s)
Back injury
Neck injury
Head injury

Surgeries

	Date	Comments
Appendectomy
Dental
Gallbladder
Hernia
Hysterectomy
Tonsillectomy
Joint replacement
Heart surgery

Hospitalizations

Date	Reason

Symptom Review

Please check if these symptoms occur presently or have occurred in the last 6
months.

General

	Mild	Moderate	Severe
Cold hands and feet	Mild	Moderate	Severe
Cold hands and feet	Mild	Moderate	Severe
Cold intolerance	Mild	Moderate	Severe
Daytime sleepiness	Mild	Moderate	Severe
Difficulty falling asleep	Mild	Moderate	Severe
Early waking	Mild	Moderate	Severe
Fatigue	Mild	Moderate	Severe
Fever	Mild	Moderate	Severe
Flushing	Mild	Moderate	Severe
Heat intolerance	Mild	Moderate	Severe
Night waking	Mild	Moderate	Severe
Nightmares	Mild	Moderate	Severe
Can't remember dreams	Mild	Moderate	Severe
Low body temperature	Mild	Moderate	Severe

Head, Eyes, and Ears

	Mild	Moderate	Severe
Conjunctivitis	Mild	Moderate	Severe
Distorted sense of smell	Mild	Moderate	Severe
Distorted taste	Mild	Moderate	Severe
Ear fullness	Mild	Moderate	Severe
Ear ringing/buzzing	Mild	Moderate	Severe
Eye crusting	Mild	Moderate	Severe
Eye pain	Mild	Moderate	Severe
Eyelid margin redness	Mild	Moderate	Severe
Headache	Mild	Moderate	Severe
Hearing loss	Mild	Moderate	Severe
Hearing problems	Mild	Moderate	Severe
Migraine	Mild	Moderate	Severe
Sensitivity to loud noises	Mild	Moderate	Severe
Vision problems	Mild	Moderate	Severe

Musculoskeletal

	Mild	Moderate	Severe
Back muscle spasm	Mild	Moderate	Severe
Calf cramps	Mild	Moderate	Severe
Chest tightness	Mild	Moderate	Severe
Foot cramps	Mild	Moderate	Severe
Joint deformity	Mild	Moderate	Severe
Joint pain	Mild	Moderate	Severe
Joint redness	Mild	Moderate	Severe
Joint stiffness	Mild	Moderate	Severe
Muscle pain	Mild	Moderate	Severe
Muscle spasms	Mild	Moderate	Severe
Muscle stiffness	Mild	Moderate	Severe
Muscle twitches ...	Mild	Moderate	Severe
... around eyes	Mild	Moderate	Severe
... in arms or legs	Mild	Moderate	Severe
Muscle weakness	Mild	Moderate	Severe
Neck muscle spasm	Mild	Moderate	Severe
Tendonitis	Mild	Moderate	Severe
Tension headache	Mild	Moderate	Severe
TMJ (temporomandibular joint) problems	Mild	Moderate	Severe

Mood/Nerves

	Mild	Moderate	Severe
Agoraphobia	Mild	Moderate	Severe
Anxiety	Mild	Moderate	Severe
Auditory hallucinations	Mild	Moderate	Severe
Blackouts	Mild	Moderate	Severe
Depression	Mild	Moderate	Severe
Difficulty concentrating	Mild	Moderate	Severe
Difficulty with balance	Mild	Moderate	Severe
Difficulty with thinking	Mild	Moderate	Severe
Difficulty with judgment	Mild	Moderate	Severe
Difficulty with speech	Mild	Moderate	Severe
Difficulty with memory	Mild	Moderate	Severe
Dizziness (spinning)	Mild	Moderate	Severe
Fainting	Mild	Moderate	Severe
Fearfulness	Mild	Moderate	Severe
Irritability	Mild	Moderate	Severe
Light-headedness	Mild	Moderate	Severe
Numbness	Mild	Moderate	Severe
Other phobias	Mild	Moderate	Severe
Panic attacks	Mild	Moderate	Severe
Paranoia	Mild	Moderate	Severe
Seizures	Mild	Moderate	Severe
Suicidal thoughts	Mild	Moderate	Severe
Tingling	Mild	Moderate	Severe
Tremor/trembling	Mild	Moderate	Severe
Visual hallucinations	Mild	Moderate	Severe

Cardiovascular

	Mild	Moderate	Severe
Angina/chest pain	Mild	Moderate	Severe
Breathlessness	Mild	Moderate	Severe
Heart attack	Mild	Moderate	Severe
Heart murmur	Mild	Moderate	Severe
High blood pressure	Mild	Moderate	Severe
Irregular pulse	Mild	Moderate	Severe
Mitral valve prolapse	Mild	Moderate	Severe
Palpitations	Mild	Moderate	Severe
Phlebitis	Mild	Moderate	Severe
Swollen ankles/feet	Mild	Moderate	Severe
Varicose veins	Mild	Moderate	Severe

Urinary

	Mild	Moderate	Severe
Bed wetting	Mild	Moderate	Severe
Hesitancy	Mild	Moderate	Severe
Infection	Mild	Moderate	Severe
Kidney disease	Mild	Moderate	Severe
Kidney stone	Mild	Moderate	Severe
Leaking/incontinence	Mild	Moderate	Severe
Pain/burning	Mild	Moderate	Severe
Urgency	Mild	Moderate	Severe

Digestion

	Mild	Moderate	Severe
Anal spasms	Mild	Moderate	Severe
Bad teeth	Mild	Moderate	Severe
Bleeding gums	Mild	Moderate	Severe
Bloating of lower abdomen	Mild	Moderate	Severe
Bloating of whole abdomen	Mild	Moderate	Severe
Bloating after meals	Mild	Moderate	Severe
Blood in stools	Mild	Moderate	Severe
Burping	Mild	Moderate	Severe
Canker sores	Mild	Moderate	Severe
Cold sores	Mild	Moderate	Severe
Constipation	Mild	Moderate	Severe
Cracking at corner of lips	Mild	Moderate	Severe
Dentures w/poor chewing	Mild	Moderate	Severe
Diarrhea	Mild	Moderate	Severe
Difficulty swallowing	Mild	Moderate	Severe
Dry mouth	Mild	Moderate	Severe
Farting	Mild	Moderate	Severe
Fissures	Mild	Moderate	Severe
Foods 'repeat' (reflux)	Mild	Moderate	Severe
Heartburn	Mild	Moderate	Severe
Hemorrhoids	Mild	Moderate	Severe
Intolerance to lactose	Mild	Moderate	Severe
Intolerance to all dairy products	Mild	Moderate	Severe
Intolerance to gluten (wheat)	Mild	Moderate	Severe
Intolerance to corn	Mild	Moderate	Severe
Intolerance to eggs	Mild	Moderate	Severe
Intolerance to fatty foods	Mild	Moderate	Severe
Intolerance to yeast	Mild	Moderate	Severe
Liver disease/jaundice (yellow eyes or skin)	Mild	Moderate	Severe
Lower abdominal pain	Mild	Moderate	Severe
Mucus in stools	Mild	Moderate	Severe
Nausea	Mild	Moderate	Severe
Periodontal disease	Mild	Moderate	Severe
Sore tongue	Mild	Moderate	Severe
Strong stool odor	Mild	Moderate	Severe
Undigested food in stools	Mild	Moderate	Severe
Upper abdominal pain	Mild	Moderate	Severe
Vomiting	Mild	Moderate	Severe

Eating

	Mild	Moderate	Severe
Binge eating	Mild	Moderate	Severe
Bulimia	Mild	Moderate	Severe
Can't gain weight	Mild	Moderate	Severe
Can't lose weight	Mild	Moderate	Severe
Carbohydrate craving	Mild	Moderate	Severe
Carbohydrate intolerance	Mild	Moderate	Severe
Poor appetite	Mild	Moderate	Severe
Salt cravings	Mild	Moderate	Severe
Frequent dieting	Mild	Moderate	Severe
Sweet cravings	Mild	Moderate	Severe
Caffeine dependency	Mild	Moderate	Severe

Respiratory

	Mild	Moderate	Severe
Bad breath	Mild	Moderate	Severe
Bad odor in nose	Mild	Moderate	Severe
Cough - dry	Mild	Moderate	Severe
Cough - productive	Mild	Moderate	Severe
Hayfever - Spring	Mild	Moderate	Severe
Hayfever - Summer	Mild	Moderate	Severe
Hayfever - Fall	Mild	Moderate	Severe
Hayfever - Change of Season	Mild	Moderate	Severe
Hoarseness	Mild	Moderate	Severe
Nasal stuffiness	Mild	Moderate	Severe
Nose bleeds	Mild	Moderate	Severe
Post nasal drip	Mild	Moderate	Severe
Sinus fullness	Mild	Moderate	Severe
Sinus infection	Mild	Moderate	Severe
Snoring	Mild	Moderate	Severe
Sore throat	Mild	Moderate	Severe
Wheezing	Mild	Moderate	Severe
Winter stuffiness	Mild	Moderate	Severe

Nails

	Mild	Moderate	Severe
Bitten	Mild	Moderate	Severe
Brittle	Mild	Moderate	Severe
Curve up	Mild	Moderate	Severe
Frayed	Mild	Moderate	Severe
Fungus - fingers	Mild	Moderate	Severe
Fungus - toes	Mild	Moderate	Severe
Pitting	Mild	Moderate	Severe
Ragged cuticles	Mild	Moderate	Severe
Ridges	Mild	Moderate	Severe
Soft	Mild	Moderate	Severe
Thickening of finger nails	Mild	Moderate	Severe
Thickening of toe nails	Mild	Moderate	Severe
White spots/lines	Mild	Moderate	Severe

Lymph Nodes

	Mild	Moderate	Severe
Enlarged (neck)	Mild	Moderate	Severe
Tender (neck)	Mild	Moderate	Severe
Other enlarged/tender lymph nodes	Mild	Moderate	Severe

Skin, Dryness of

	Mild	Moderate	Severe
Eyes	Mild	Moderate	Severe
Feet	Mild	Moderate	Severe
Feet - any cracking?	Mild	Moderate	Severe
Feet - any peeling?	Mild	Moderate	Severe
Hair	Mild	Moderate	Severe
Hair - also unmanageable?	Mild	Moderate	Severe
Hands	Mild	Moderate	Severe
Hands - any cracking?	Mild	Moderate	Severe
Hands - any peeling?	Mild	Moderate	Severe
Mouth/throat	Mild	Moderate	Severe
Scalp	Mild	Moderate	Severe
Dandruff	Mild	Moderate	Severe
Skin in general	Mild	Moderate	Severe

Skin Problems

	Mild	Moderate	Severe
Acne on back	Mild	Moderate	Severe
Acne on chest	Mild	Moderate	Severe
Acne on face	Mild	Moderate	Severe
Acne on shoulders	Mild	Moderate	Severe
Athlete's foot	Mild	Moderate	Severe
Bumps on back of upper arms	Mild	Moderate	Severe
Cellulite	Mild	Moderate	Severe
Dark circles under eyes	Mild	Moderate	Severe
Ears get red	Mild	Moderate	Severe
Easy bruising	Mild	Moderate	Severe
Eczema	Mild	Moderate	Severe
Herpes - genital	Mild	Moderate	Severe
Hives	Mild	Moderate	Severe
Jock itch	Mild	Moderate	Severe
Lackluster skin	Mild	Moderate	Severe
Moles w/ color or size change	Mild	Moderate	Severe
Oily skin	Mild	Moderate	Severe
Pale skin	Mild	Moderate	Severe
Patchy dullness	Mild	Moderate	Severe
Psoriasis	Mild	Moderate	Severe
Rash	Mild	Moderate	Severe
Red face	Mild	Moderate	Severe
Sensitive to bites	Mild	Moderate	Severe
Sensitive to poison ivy/oak	Mild	Moderate	Severe
Shingles	Mild	Moderate	Severe
Skin cancer	Mild	Moderate	Severe
Skin darkening	Mild	Moderate	Severe
Strong body odor	Mild	Moderate	Severe
Thick calluses	Mild	Moderate	Severe
Vitiligo	Mild	Moderate	Severe

Itching Skin

	Mild	Moderate	Severe
Anus	Mild	Moderate	Severe
Arms	Mild	Moderate	Severe
Ear canals	Mild	Moderate	Severe
Eyes	Mild	Moderate	Severe
Feet	Mild	Moderate	Severe
Hands	Mild	Moderate	Severe
Legs	Mild	Moderate	Severe
Nipples	Mild	Moderate	Severe
Nose	Mild	Moderate	Severe
Genitals	Mild	Moderate	Severe
Roof of mouth	Mild	Moderate	Severe
Scalp	Mild	Moderate	Severe
Skin in general	Mild	Moderate	Severe
Throat	Mild	Moderate	Severe

Female Reproductive

	Mild	Moderate	Severe
Breast cysts	Mild	Moderate	Severe
Breast lumps	Mild	Moderate	Severe
Breast tenderness	Mild	Moderate	Severe
Ovarian cyst	Mild	Moderate	Severe
Poor libido (sex drive)	Mild	Moderate	Severe
Endometriosis	Mild	Moderate	Severe
Fibroids	Mild	Moderate	Severe
Infertility	Mild	Moderate	Severe
Vaginal discharge	Mild	Moderate	Severe
Vaginal odor	Mild	Moderate	Severe
Vaginal itch	Mild	Moderate	Severe
Vaginal pain	Mild	Moderate	Severe
Premenstrual bloating	Mild	Moderate	Severe
Premenstrual breast tenderness	Mild	Moderate	Severe
Premenstrual carbohydrate craving	Mild	Moderate	Severe
Premenstrual chocolate craving	Mild	Moderate	Severe
Premenstrual constipation	Mild	Moderate	Severe
Premenstrual decreased sleep	Mild	Moderate	Severe
Premenstrual diarrhea	Mild	Moderate	Severe
Premenstrual fatigue	Mild	Moderate	Severe
Premenstrual increased sleep	Mild	Moderate	Severe
Premenstrual irritability	Mild	Moderate	Severe
Menstrual cramps	Mild	Moderate	Severe
Heavy periods	Mild	Moderate	Severe
Irregular periods	Mild	Moderate	Severe
No periods	Mild	Moderate	Severe
Scanty periods	Mild	Moderate	Severe
Spotting between periods	Mild	Moderate	Severe

Medication/Supplements

Medications (include prescription and over-the-counter)
If a medication was something you no longer take but did at some point in the past, please tick the box in the
column "Past?". This might also include medications or anesthetics given in relation to a surgery, procedure or
hospitalisation.

Medication	Dosage	Start Date (mo/yr)	Reason For Use	Past?
				Past?
				Past?
				Past?
				Past?
				Past?

Nutritional supplements (vitamins/minerals/herbs etc.)

Name & Brand	Dosage	Start Date (mo/yr)	Reason For Use

Have medications or supplements ever caused unusual side effects or problems?
YesNo

Have you used any of these regularly for a long time:

	Yes	No
NSAIDs (ibuprofen, naproxen), Aspirin	Yes	No
Paracetamol (acetaminophen, Tylenol)	Yes	No
Acid-blocking drugs / PPIs (omeprazole, esomeprazole, Zantac, Prilosec, Nexium, etc.)	Yes	No

How many times have you taken antibiotics?

	<5 Times	>5 Times
Infancy/Childhood	<5 Times	>5 Times
Teen	<5 Times	>5 Times
Adulthood	<5 Times	>5 Times

Have you ever taken long-term antibiotics?
YesNo

How often have you taken oral steroids (e.g. cortisone, prednisone, etc.)?

	<5 Times	>5 Times
Infancy/Childhood	<5 Times	>5 Times
Teen	<5 Times	>5 Times
Adulthood	<5 Times	>5 Times

Readiness Assessment and Health Goals

In order to improve your health, how willing are you to:
Rate on a scale of 1 (not willing) to 5 (very willing)

	1	2	3	4	5
Significantly modify your diet	1	2	3	4	5
Take several nutritional supplements each day	1	2	3	4	5
Keep a record of everything you eat each day	1	2	3	4	5
Modify your lifestyle (e.g. work demands, sleep habits)	1	2	3	4	5
Practice a relaxation technique	1	2	3	4	5
Engage in regular exercise	1	2	3	4	5

How confident are you of your ability to organize and follow through on the above health-related activities
1 = not confident at all, 5 = very confident
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If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?