ADULT MEDICAL QUESTIONNAIREhealthyendeavorsmed.com/wp-content/uploads/2019/06/... · More than 3x/day l-3x/day 4-6x/week 2-3x/week 1 or fewer x/week b. Consistency Soft and well forme

ADULT MEDICAL QUESTIONNAIRE

Our ability to draw effective conclusions about your present state of health and how to improve it depends, to asignificant extent, on your ability to respond thoughtfully and accurately to both these written questions and thoseposed by the clinician during your consultations. Health issues are usually influenced by many factors. Accuratelyassessing all the factors and comprehensively managing them is the best way to deal with these health challenges.Your careful consideration of each of the following questions will enhance our efficiency and will provide for moreeffective use of your scheduled consultation time. These questions will help to identify underlying causes of illnessand will also assist us to formulate a treatment plan.

First Name:

Address:

Middle Name: Last Name:

. City.. State: ZIP:

Home Phone: ( Birth Date:month day year

Work Phone: (_

Occupation:

Place of Birth:

Referred by:

Today's Date

City or town & country if not US

Height: ' " Weight:. Sex:

1. Please check appropriate box(es):

D African American D Hispanic D MediterraneanD Native American D Caucasian D Northern European

2. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:

D AsianD Other

DESCRIBE PROBLEM

Example: Post Nasal Dripa.b.c.d.e.f.

g-

MILD/MODERATE/

SEVEREModerate

TREATMENTAPPROACH

Elimination DietSUCCESS

Moderate

©Copyright The Institute for Functional Medicine

Adult Medical Questionnaire

3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)Example: Wendy, age 7, sister

4. Do you have any pets or farm animals? Yes No_If yes, where do they live? 1. indoors 2. outdoors 3. both indoors and outdoors

5. Have you lived or traveled outside of the United States? Yes NoIf so, when and where?

6. Have you or your family recently experienced any major life changes? Yes No_If yes, please comment:

7. Have you experienced any major losses in life? Yes No_If so, please comment:

8. How important is religion (or spirituality) for you and your family's life?a. not at all importantb. somewhat importantc. extremely important

9. How much time have you lost from work or school in the past year?a. 0-2 daysb. 3 -14 daysc. > 15 days

10. Previous jobs:

11. Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors tochronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be verytraumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in yourlife, it is very important that you feel safe telling us about it, so that we can support you and optimize yourtreatment outcomes.

Please do your best to answer the following questions:a. Did you feel safe growing up?

D Yes D No

b. Have you been involved in abusive relationships in your life?D Yes D No

c. Was alcoholism or substance abuse present in your childhood home, or is it present now in yourrelationships?D Yes D No

d. Do you currently feel safe in your home?DYes DNo



e. Do you feel safe, respected and valued in your current relationship?D Yes D No

f. Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violenceor abuse?D Yes D No

g. Would you feel safer discussing any of these issues privately?D Yes D No

12. Past Medical and Surgical History:

ILLNESSESa. Anemiab. Arthritisc. Asthmad. Bronchitise. Cancerf. Chronic Fatigue Syndromeg. Crohn's Disease or Ulcerative Colitish. Diabetesi. Emphysemaj. Epilepsy, convulsions, or seizuresk. Gallstones1. Gout

ILLNESSESm. Heart attack/ Anginan. Heart failureo. Hepatitisp. High blood fats (cholesterol, triglycerides)q. High blood pressure (hypertension)r. Irritable bowels. Kidney stonest. Mononucleosisu. Pneumoniav. Rheumatic feverw. Sinusitisx. Sleep apneay. Strokez. Thyroid diseaseaa. Other (describe)

INJURIES

ab. Back injuryac. Broken (describe)

WHEN

WHEN

WHEN

COMMENTS

COMMENTS

COMMENTS



ad. Head injury

ae. Neck injury

af. Other (describe)DIAGNOSTIC STUDIES

ag. Barium Enemaah. Bone Scanai. CAT Scan of Abdomenaj. CAT Scan of Brainak. CAT Scan of Spineal. Chest X-rayam. Colonoscopyan. EKGao. Liver scanap. Neck X-rayaq. NMR/MRIar. Sigmoidoscopyas. Upper GI Seriesat Other (describe)

WHEN COMMENTS



OPERATIONSau. Appendectomyav. Dental Surgeryaw. Gall Bladderax. Herniaay. Hysterectomyaz. Tonsillectomyba. Other (describe)bb. Other (describe)

WHEN COMMENTS

13. Hospitalizations:

WHERE HOSPITALIZEDa.b.c.d.e.

WHEN FOR WHAT REASON

14. How often have you have taken antibiotics?< 5 times > 5 times

Infancy/ ChildhoodTeenAdulthood

15. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?< 5 rimes > 5 rimes

Infancy/ ChildhoodTeenAdulthood

16. What medications are you taking now? Include non-prescription drugs.Medication Name

1.2.3.4.5.6.7.8.

Date started Dosage



17. Are you allergic to any medications?If yes, please list:

Yes No

18. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg orIU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.

Vitamin/Mineral/Supplement Name1.2.3.4.5.6.7.8.

Date started Dosage

19. Childhood:Question

1. Were you a full term baby?a. A preemie?b. Breast fed?c. Bottle fed?

2. As a child did you eat a lot of sugar and/or candy?

Yes No Don'tEnow

Comment

20. As a child, were there any foods that you had to avoid because they gave you symptoms?Yes No_

If yes, please: name the food and symptom (Example: milk — gas and diarrhea)

21. Pkce a check mark next to the food/drink that applies to your current diet. (List continues on next page.)

a.b.c.d.e.f.frh.i.

j-k.1.m.n.

Usual BreakfastNoneBacon/ SausageBagelButterCerealCoffeeDonutEggsFruitJuiceMargarineMilkOat branSugar

Va.b.c.d.e.£g-h.i.)•k.1.m.n.

Usual LunchNoneButterCoffeeEat in a cafeteriaEat in restaurantFish sandwichJuiceLeftoversLettuceMargarineMayoMeat sandwichMilkSakd

Va.b.c.d.e.f.g-h.i.)•k.1.m.n.

Usual DinnerNoneBeans (legumes)Brown riceButterCarrotsCoffeeFishGreen vegetablesJuiceMargarineMilkPastaPotatoPoultry

V



o.p-q-r.s.tu.V.

Usual BreakfastSweet rollSweetenerTeaToastWaterWheat branYogurtOther: (List below)

V0.

P-q-r.s.tu.V.

w.X.

Usual LunchSalad dressingSodaSoupSugarSweetenerTeaTomatoWaterYogurtOther: (List below)

V0.

P-q-r.s.tu.V.

w.X.

y-

Usual DinnerRed meatRiceSakdSalad dressingSodaSugarSweetenerTeaWaterYellow vegetablesOther: (list below)

V

22. How much of the following do you consume each week?

a.b.c.d.e.£

g-h.i.

j-k.1.m.

CandyCheeseChocokteCups of coffee containing caffeineCups of decaffeinated coffee or teaCups of hot chocolateCups of tea containing caffeineDiet sodasIce creamSalty foodsSlices of white bread (rolls/bagels)Sodas with caffeineSodas without caffeine

23. Are you on a special diet?ovo-lactodiabeticdairy restricted

. vegetarian

.vegan

. blood type diet

Yes No. other (describe):

24. Is there anything special about your diet that we should know?If yes, please explain:

Yes No

25. a. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?Yes No

b. If yes, are these symptoms associated with any particular food or supplement(s)?Yes No

c. Please name the food or supplement and symptom(s). Example: Milk — gas and diarrhea.

26. Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evidentfor 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes No



27. Do you feel much worse when you eat a lot of:Jiigh fat foodsJiigh protein foodsJiigh carbohydrate foods(breads, pastas, potatoes)

28. Do you feel much better when you eat a lot of:high fat foodshigh protein foodshigh carbohydrate foods(breads, pastas, potatoes)

29, Does skipping a meal greatly affect your symptoms?

_refined sugar (junk food)_fcied foods_1 or 2 alcoholic drinks..other

.refined sugar (junk food)_fried foods_1 or 2 alcoholic drinksother

Yes

30. Have you ever had a food that you craved or really "binged" on over a period of time?Food craving may be an indicator that you may be allergic to that food. YesIf yes, what food(s)?

No

No

31. Do you have an aversion to certain foods?If yes, what foods?

Yes No

32. Please fill in the chart below with information about your bowel movements:

a. FrequencyMore than 3x/dayl-3x/day4-6x/week2-3x/week1 or fewer x/week

b. ConsistencySoft and well formedOften floatDifficult to passDiarrheaThin, long or narrowSmall and hardLoose but not wateryAlternating between hard

and loose/watery

V b. ColorMedium brown consistentlyVery dark or blackGreenish colorBlood is visible.Varies a lot.Dark brown consistentlyYellow, light brownGreasy, shiny appearance

V

33. Intestinal gas: .Daily^OccasionallyExcessive

34. a. Have you ever used alcohol?b. If yes, how often do you now drink alcohol?

Present with painFoul smellingLittle odor

Yes NoNo longer drinking alcoholAverage 1-3 drinks per weekAverage 4-6 drinks per weekAverage 7-10 drinks per weekAverage >10 drinks per week



c. Have you ever had a problem with alcohol? Yes_If yes, please indicate time period (month/year): from to

35. Have you ever used recreational drugs? Yes_

36. Have you ever used tobacco? Yes_If yes, number of years as a nicotine user . Amount per day . Year quitIf yes, what type of nicotine have you used? Cigarette

Cigar

37. Are you exposed to second hand smoke regularly?

38. Do you have mercury amalgam fillings?

39. Do you have any artificial joints or implants?

No

No

No

40. Do you feel worse at certain times of the year?If yes, when? spring

summer

Year quitSmokeless

Pipe

Yes No

Patch/Gum

Yes No

Yes No

Yes NoJailwinter

41. Have you, to your knowledge, been exposed to toxic metals in your job or at home? Yes No_If yes, which one(s)? lead cadmium

arsenic mercuryaluminum

42. Do odors affect you?

43. How well have things been going for you?

Yes No

a. At schoolb. In your jobc. In your social lifed. With close friendse. With sexf. With your attitudeg. With your boyfriend/girlfriendh. With your childreni. With your parentsj. With your spouse

Very Well Fair Poorly VeryPoorly

Does notapply

44. Have you ever had psychotherapy or counseling?Currently? Previously? If previously, from toWhat kind?Comments:

Yes No

45. Are you currently, or have you ever been, married?If so, when were you married? Spousefs occupation.When were you separated? NeverWhen were you divorced? Never

Yes No



When were you remarried?Comments:

Never Spouse's occupation.

46. Hobbies and leisure activities:

47. Do you exercise regularly?If so, how many times a week?

1. Ix2. 2x3. 3x4. 4x or more

What type of exercise is it?jogging/ walkingbasketballhome aerobics

Yes NoWhen you exercise, how long is each session?1. 45 min

Jiennis_water sportsother



48. Any other family history we should know about? Yes No_If so, please comment:

49. What is the attitude of those close to you about your illness?SupportiveNon-supportive

FOR WOMEN ONLY (questions 50-58):

50. Have you ever been pregnant? (If no, skip to question 53.) Yes No_

Number of miscarriages Number of abortions Number of preemies

Number of term births Birth weight of largest baby Smallest baby

Did you develop toxemia (high blood pressure)? Yes No

Have you had other problems with pregnancy? Yes No

If so, please comment:

51. Age at first period Date of kst Pap Smear Date of kst Mammogram_Pap Smear: Normal AbnormalMammogram: Normal Abnormal

52. Have you ever used birth control pills? Yes No If yes, when

53. Are you taking the pill now? Yes No

54. Did taking the pill agree with you? Yes No Not applicable.

55. Do you currently use contraception? Yes NoIf yes, what type of contraception do you use?

56. Are you in menopause? No Yes If yes, age at kst period_Do you take: Estrogen? Ogen? Estrace? Premarin? Other (specify)..

Progesterone? Provera? Other (specify)

57. How long have you been on hormone repkcement therapy (if applicable)? —

58. In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability(PMS)? Yes No Not applicable



59. Please check if these symptoms occurpresently or have occurred in the past 6 months.

GENERAL:

Cold hands & feetCold intoleranceDaytime sleepinessDifficulty felling asleepEarly wakingFatigueFeverFlushingHeat intoleranceNight wakingNightmaresNo dream recall

Mild Mod-erate

Severe

HEAD, EYES & EARS:

ConjunctivitisDistorted sense of smellDistorted tasteEar fullnessEar noisesEar painEar ringing/buzzingEye crustingEye painHeadacheHearing lossHearing problemslid margin rednessMigraineSensitivity to loud noisesVision problems

MUSCULOSKELETAL:

Back muscle spasmCalf crampsChest tightnessFoot crampsJoint deformityJoint painJoint rednessJoint stiffnessMuscle painMuscle spasmsMuscle stiffnessMuscle twitches:

Around eyesArms or legs

Muscle weaknessNeck muscle spasmTendonitisTension headacheTMJ problems

Mild Mod-erate

Severe

MOOD/NERVES:

AgoraphobiaAnxietyAuditory hallucinationsBlack-outDepressionDifficulty:

ConcentratingWith balanceWith thinkingWith judgmentWith speechWith memory

Dizziness (spinning)FaintingTearfulnessIrritabilityUght-headedness



MOOD/NERVES, Cont’d

Mild Mod-erate

Severe

NumbnessOther PhobiasPanic attacksParanoiaSeizuresSuicidal thoughtsTinglingTremor/ tremblingVisual hallucinations

EATING:

Binge eatingBulimiaCan't gain weightCan't lose weightCarbohydrate cravingCarbohydrate intolerancePoor appetiteSalt craving

DIGESTION:

Anal spasmsBad teethBleeding gumsBloating of: Lower abdomen

Whole abdomenBlood in stoolsBurpingCanker soresCold soresConstipationClacking at comer of hipsDentures w/poor chewingDiarrheaDifficulty swallowingDry mouthIntestinal gas

DIGESTION, Cont’d- Mild Mod-erate Severe

FissuresFoods “repeat” (reflux)HeartburnHemorrhoidsIntolerance to: Lactose

All milk productsIntolerance to: Gluten (wheat)

CornEggsFatty foodsYeast

Liver disease/jaundice(yellow eyes or skin)

Lower abdominal painMucus in stoolsNauseaPeriodontal diseaseSore tongueStrong stool odorUndigested food in stoolsUpper abdominal painVomiting

SKIN PROBLEMS:

Acne on backAcne on chestAcne on faceAcne on shouldersAthlete's footBumps on back of upper armsCelluliteDark circles under eyesEars get tedEasy bruising



SKIN PROBLEMS,Cont*d:

EczemaHerpes - genitalHivesJock itchLackluster skinMoles w color/ size changeOily skinPale skinPatchy dullnessPsoriasisRashRed feceSensitive to bitesSensitive to poison ivy/oakShinglesSkin cancerSkin darkeningStrong body odorThick callusesVitiligo

Mild Mod-erate

Severe

SKIN, ITCHING:

AnusArmsEar canalsEyesFeetHandsLegsNipplesNosePenisRoof of mouthScalpSkin in generalThroat

SKIN, DRYNESS OF:

EyesFeet

Any cracking?Any peeling?

HairAnd unmanageable?

HandsAny cracking?Any peeling?

Mouth/throatScalp

Any dandruff?Skin in general

Mild Mod-erate

Severe

LYMPH NODES:

Enlarged/neckTender/neckOther enlarged/tenderlymph nodes

NAILS:

BittenBritdeCurve upFrayedFungus - fingersFungus - toesPittingRagged cuticlesRidgesSoftThickening of:

FingernailsToenails

White spots/lines



RESPIRATORY:

Bad breathBad odor in noseCough - dryCough - productiveHay fever : Spring

SummerFallChange of season

HoarsenessNasal stuffinessNose bleedsPost nasal dripSinus fullnessSinus infectionSnoringSore throatWheezingWinter stuffiness

Mild Mod-erate

Severe

CARDIOVASCULAR:

Angina/chest painBreathlessnessHeart attackHeart murmurHigh blood pressureIrregular pulseMitral valve prolapsePalpitationsPhlebitisSwollen ankles/feetVaricose veins

URINARY:

Bed wetting

HesitancyInfection

Kidney diseaseKidney stoneleaking/incontinencePain/burningProstate enlargementProstate infectionUrgency

Mild Mod-erate

Severe

MALEREPRODUCTIVE:

Discharge from penisEjaculation problemGenital painImpotenceInfectionLumps in testiclesPoor libido (sex drive)

FEMALEREPRODUCTIVE:

Breast cystsBreast lumpsBreast tendernessOvarian cystPoor libido (sex drive)EndometriosisFibroidsInfertilityVaginal dischargeVaginal odorVaginal itchVaginal pain


Name

Medical Symptoms QuestionnaireDate

Rate each of the following symptoms based upon your typical health profile for:D Past 30 days D Past 48 hours

Point Scale

HEAD

0 • Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severe

HeadachesFaintnessDizzinessInsomnia

EYES

EARS

NOSE

MQUTHfFHROAT

SKIN

HEART

Total.

Watery or itchy eyesSwollen, reddened or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision(does not include near or far-sightedness) Total

Itchy earsEaraches, ear infectionsDrainage from earRinging in ears, hearing loss

Stuffy noseSinus problemsHay feverSneezing attacksExcessive mucus formation

Total

Total

Chronic coughingGagging, frequent need to dear throatSore throat, hoarseness, loss of voiceSwollen or discolored tongue, gums, lipsCanker sores Total

AcneHives, rashes, dry skinHair lossFlushing, hot flashesExcessive sweating

Irregular or skipped heartbeatRapid or pounding heartbeatChest pain

Total

Total

Applying Functional Medicine in Clinical Practice

Medical Symptoms Questionnaire Page 2

LUNGS

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

GRAND TOTAL

Chest congestionAsthma, bronchitisShortness of breathDifficulty breathing

Nausea, vomitingDiarrheaConstipationBloated feelingBelching, passing gasHeartburnIntestinal/stomach pain

Pain or aches in jointsArthritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tiredness

Binge eating/drinkingCraving certain foodsExcessive weightCompulsive eatingWater retentionUnderweight

Fatigue, sluggishnessApathy, lethargyHyperactivityRestlessness

Poor memoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilities

Mood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepression

Frequent illnessFrequent or urgent urinationGenital itch or discharge

Total

Total.

Total

Total

Total

Total

Total

Total.

TOTAL

Applying Functional Medicine in Clinical Practice

Documents

ADULT MEDICAL QUESTIONNAIREhealthyendeavorsmed.com/wp-content/uploads/2019/06/... · More than 3x/day l-3x/day 4-6x/week 2-3x/week 1 or fewer x/week b. Consistency Soft and well forme