Functional Gastro Female Intake Questionnaire

Functional Gastro Female Intake Questionnaire
General Information
Name
Age
Today's Date

Month Day Year
Date
Date of Birth

Month Day Year
Date
Email
example@example.com
Address

Address

Street Address Line 2

City State

Zip
Phone (Home)
(Cell)
(Work)
Genetic Background

African American Mediterranean Asian (Work) Native American Caucasian Northern European Other
When, where and from whom did you last receive medical or health care?
Emergency Contact
Relationship
Phone (Home)
(Cell)
(Work)
How did you hear about our practice?

Clinic website IFM website Referral from doctor Referral from friend/family member Social media Other

Please rank current and ongoing health concerns in order of priority

	Describe Problem	Mild	Moderate	Severe	Prior Treatment/ Approach	Excellent	Good	Fair
1
2
3
4
5
6
7
8

Allergies

Please rank current and ongoing health concerns in order of priority

	Name of Medication/Supplement /Food:	Reaction:
1
2
3
4
5

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

	Yes	No
Do you have problems falling asleep?
Do you have problems with insomnia?
Do you feel rested upon awakening?
Staying asleep?
Do you snore?

Do you use sleep aids?

Yes No
If yes, explain
Exercise

Current Exercise Program

	Type	#of Times Per Week	Time/Duration (Minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (eg. golf)
Others:

Do your feel motivated to exercise?

Yes No A little
Are there any problems to exercise?

Yes No
If yes, explain
Do you feel fatigued or sore after exercise?

Yes No
If yes, explain
Nutrition
Do you currently follow any of the following special diets or nutritional program? (check all that apply)

Vegetarian Vegan Allergy Elimination Low Fat Low Carb High Protein Blood Type Low Sodium No Dairy No Wheat Gluten Free Other
Do you have food sensitivities to certain foods?

Yes No
If yes, list food and symptoms:
Do you have an aversion to certain foods?

Yes No
If yes, explain
Do you adversely react to: (Check all that apply)

Artificial sweeteners Garlic/onion Cheese Citrus foods Monosodium glutamate (MSG) Chocolate Alcohol Red wine Sulfite-containing foods (wine, dried fruit, salad bars) Preservatives Food colorings Other
Are there any foods that you crave or binge on?

Yes No
If yes, what foods?
Do you eat 3 meals a day?

Yes No
If no, how many
Does skipping a meal greatly affect you?

Yes No
How many meals do you eat out per week?

0-1 1-3 3-5 >5 meals per week
Check the factors that apply to your current lifestyle and eating habits:

Love to eat Eat because I have to Have negative relationship to food Struggle with eating issues Emotional eater eat when sad, lonely, bored, etc Eat too much under stress Eat too little under stress Don't care to cook Confused about nutrition advice
Check the factors that apply to your current lifestyle and eating habits: (cont.)

Fast eater Significant other or family members Eat too much Late-night eating Dislike healthy foods Time constraints Travel frequently Eat more than 50% of meals away from home Healthy foods not readily available Poor snack choices Significant other or family members don't like
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?

Yes No
If yes, check amounts:
Coffee (cups per day)

1 2-4 >4
Tea (cups per day)

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

1 2-4 >4
Do you have adverse reactions to caffeine?

Yes No
If yes, explain
When you drink caffeine do you feel

Irritable or wired Aches or pains
Do you smoke currently?

Yes No:
If yes,
Packs per day:
Number of years:
What type?

Smokeless Cigarettes Pipe Cigar E-Cig
Have you attempted to quit?

Yes No
If yes, using what methods
If you smoked previously:
Packs per day
Number of years
Are you regularly exposed to second-hand smoke?

No Yes
How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)

1-3 4-6 7-10 >10 None
Previous alcohol intake?

Yes None
If yes,

Mild Moderate High
Have you ever had a problem with alcohol?

Yes No
If yes, when?
Explain the problem
Have you ever thought about getting help to control or stop your drinking?

Yes No
Are you currently using any recreational drugs?

Yes No
If yes, type
Have you ever used IV or inhaled recreational drugs?

Yes No
Do you feel you have an excessive amount of stress in your life?

Yes No
Do you feel you can easily handle the stress in your life?

Yes No
How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)
Work
Family
Social
Finances
Health
Other
Do you use relaxation techniques?

Yes No
If yes, how often?
What techniques do you use?

Meditation Tai Chi Yoga Prayer Breathing Other
Have you ever sought counseling?

Yes No
Are you currently in therapy?

Yes No
If yes, describe
Have you ever been abused, a victim of crime, or experienced a significant trauma?

Yes No
What are your hobbies or leisure activities?
Marital status

Married Divorced Widow/er Gay/Lesbian Long-Term Partner Single
With whom do you currently live (Include children, parents, relatives, friends, pets)
Current occupation
Previous occupations
Do you have resources for emotional support?

Yes No
If yes (check all that apply)

Spouse/Partner Family Friends Religious/Spiritual Pets Other
Do you have a religious or spiritual practice?

Yes No
If yes, what kind?

How well have things been going for you? (Mark on scale of 1-10, or N/A if not applicable)

	N/A	Rate 1-10
Overall
At school
In you job
In your social life
With close friends
With sex
With your attitude
With your boyfriend/girlfriend
With your children
With your parents
With your spouse

Patient's Birth/Childhood History:
You were born

Term Premature Don't know
Were there any pregnancy or birth complications?

No Yes
If yes, explain
How long were you breast-fed?
If bottle -fed, what type of formula did you use?
Age of introduction of:
Solid food
Wheat
Dairy
As a child, were there any foods that were avoided because they gave you symptoms?

Yes No
If yes, what foods and what symptoms? (Example: milk and gas)
Did you eat a lot of sugar or candy as a child?

Yes No
Dental History:

Check if you have any of the following, and provide number if applicable:
Silver mercury fillings

Silver mercury fillings Gold fillings Root canals Implants Caps/Crowns Tooth pain Bleeding gums Gingivitis Problems with chewing Other dental concerns (explain):
Have you had any mercury fillings removed?

Yes No
If yes, when
How many fillings did you have as a kid?
Do you brush regularly?

Yes No
Do you floss regularly?

Yes No
Evnironmental/Detoxification History
Do any of these significantly affect you?

Cigarette smoke Perfume/colognes Auto exhaust fumes Other
Do you have any pets or farm animals?

Yes No
If yes, do they live

Inside Outside Both inside and outside
C 2015 The Institute for Functional Medicine6
Women's History
Obstetric History

Pregnancy(s) Miscarriage(s) Abortion(s) Vaginal Deliveries Cesarean Term Birth(s) Premature birth(s)
Birth weight of largest baby
Birth weight of smallest baby
Did you develop any problems in or after pregnancy, for example, toxemia (high blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.?

Yes No
If yes, please explain
Age at first period
Date of last menstrual period

Month Day Year
Date
Length of cycle
Time between cycles
Cramping
Pain?
If yes, please describe
Do you have other problems with your periods heavy, irregular, spotting, skipping, etc?

Yes No
If yes, please describe
Use of hormonal birth control

Patch Birth control pills Nuva ring
Use of hormonal birth control

Other Other
How Long
Any problems with hormonal birth control?

Yes No
If yes, explain
Use of other contraception?

Yes No Condoms Diaphragm IUD Partner vasectomy
Are you in menopause?

Yes No
Was menopause surgically induced?

Yes No
If yes, age at last period
Do you currently have symptomatic problems with menopause? (Check all that apply)

Hot flashes Headaches Concentration/memory problems Mood swings Joint pain Decreased libido Loss of control of urine Weight gain Vaginal dryness Palpitations
Are you on hormone replacement therapy?

Yes No
If yes, for how long and for what reason (hot flashes, osteoporosis prevention, etc.)?
Other Gynecological Symptoms: (Check if applicable)

Endometriosis Fibroids Fibrocystic breasts Vaginal infection Infertility Ovarian cysts Pelvic inflammatory disease Reproductive cancer Sexually transmitted disease (describe below) Other
Sexually transmitted disease if applicable cont...
Gynecological Screening/Procedures:

(If applicable, provide date)
Last Pap test results
Date
Mammogram
Date
Last bone density
Results

Low High Within Normal Range
Other test/procedures (list type and dates)
C 2015 The Institute for Functional Medicine
Family History

Check family members that have/had any of the following:

	Select a Family Member
Cancer
Heart disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune Disease
Arthritis
Kidney Disease
Thyroid Problems
Seizures/Epilepsy
Psychiatric disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable Bowel Syndrome
Dementia
Substance abuse
Genetic disorders

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
GERD (reflux)
Crohn's disease/ulcerative colitis
Peptic ulcer disease
Celiac disease
Gallstones
Other

Respiratory

	Yes	Past
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep apnea
Other:

Urinary/Genitals

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

Endocrine/Metabolic

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

Inflammatory/Immune

	Yes	Past
Rheumatoid arthritis
Chronic Fatigue Syndrome
Food allergies
Multiple chemical sensitivities
Autoimmune disease
Immune deficiency
Mononucleosis
Hepatitis
Other:

Musculoskeletal

	Yes	Past
Fibromyalgia
Osteoarthritis
Chronic Pain
Other:

Skin

	Yes	Past
Eczema
Psoriasis
Acne
Skin Cancer
Other:

Cardiovascular

	Yes	Past
Angina
Heart Attack
Heart Failure
Hypertension (high blood pressure)
Stroke
High blood fats (cholesterol, triglycerides)
Rheumatic fever
Arrythmia (irregular heart rate)
Murmur
Mitral valve prolapse
Other:

Neurologic/Emotional

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

Cancer

	Yes	Past
Lung
Breast
Colon
Skin
Other

Diagnostic Studies

	Date	Comments
Bone Density
CT Scan
Colonoscopy
Cardiac
EKG
MRI
Upper endoscopy
Upper GI series
Chest X-ray
Other X-ray
Barium enema
Other:

Injuries

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

Surgeries

	Date	Comments
Appendectomy
Dental
Gallbladder
Hernia
Tonsillectomy
Joint replacement
Heart surgery
Other:

Hospitalizations

	Date	Reason
1.
2.
3.
4.
5.

Symptom Review

Please check if these symptoms occure presently or have occured in the last 6 months

General

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

Head, Eyes, and Ears

	Mild	Moderate	Severe
Conjuctivitis
Distorted sense of smile
Distorted taste
Ear fullness
Ear ringing/buzzness
Eye crusting
Eye pain
Eyelid margin redness
Headache
Hearing loss
Hearing problems
Migraine
Sensitvity to loud noises
VIsion problems

Musculoskleletal

	Mild	Moderate	Severe
Back muscle spasm
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint pain
Joint redness
Muscle spasm
Muscle stifness
Muscle twitches: around eyes
Muscle twitches: arms or legs
Muscle weakness
Neck muscle spasm
Tendonitis
Tension Headache
TMJ problems

Mood/Nerves

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

Cardiovascular

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

Urinary

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

Digestion

	Mild	Moderate	Severe
Anal spasms
Bad teeth
Bleeding gums
Bloating
Blood in stool
Burping
Canker sores
Cold sores
Constipation
Cracker at corner of lips
Dentures w/ poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Farting
Fissures
Reflux
Heartburn
Hemmerrhoids
Intolerance to Lactose
Intolerance to all dairy
Intolerance to gluten (wheat)
Intolerance to corn
Intolerance to eggs
Intolerance to fatty food
Intolerance to yeast
Liver disease/Jaundice
Lower abdominal pain
Mucus in stools
Nausea

Skin Problems

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

Itchy Skin

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

Female Reproductive

	Mild	Moderate	Severe
Breast cysts
Breast lumps
Breast tenderness
Ovarian cyst
Poor libido (sex drive)
Endometriosis
Fibroids
Infertility
Vaginal discharge
Vaginal pain
Premenstrual:
Bloating
Breast tenderness
Carbohydrate craving
Chocolate craving
Constipation
Decreased sleep
Diarrhea
Fatigue
Increased sleep
Irritability
Menstrual:
Cramps
Heavy period
Irregular periods
No periods

Medication/Supplements
Current medications (include prescriptions and over-the-counter) Name/Dosage/Start Date (mo/yr)/Reason for use
Nutritional supplements (vitamin/mineral/herbs, etc.) Name/Dosage/Start Date (mo/yr)/Reason for use
Have medications or supplements ever caused unusual side effects or problems?

Yes No
If yes, describe:

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

	Yes	No
NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin
Tylenol (acetaminophen)
Acid-blocking drugs (Zantac, Prilosec, Nexium, etc)?

How many time have you taken antibiotics?

	< 5	> 5	Reason for use
Infancy/childhood
Teen
Adulthood

Have you ever taken long term antibiotics?

Yes No
If yes, explain:

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

	< 5	> 5	Reason for use
Infancy/childhood
Teen
Adulthood

Readiness Assessment

In order to improve your health, how willing are you to (5 = very willing; 1 = not willing):

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

Rate on a scale of 5 (very confident) to 1 (not confident at all): How confident are you of your ability to organize and follow through on the above health activities?

1 2 3 4 5
If you are not confident of your ability, what aspects of yourself life lead you to question your capacity to follow through?
Rate on a scale of 5 (very supportive) to 1 (very unsupportive): At the present time, how supportive do you think the people inyour household will be to your implementing the above changes?

5 4 3 2 1
Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact): How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful toyou as you implement your personal health program?

5 4 3 1
Comments
C 2015 The Institute for Functional Medicine
What do you hope to achieve in your visit with us?
When was the last time you felt well?
Did something trigger your change in health?
What makes you feel better?
What makes you feel worse?
How does your condition affect you?
What do you think is happening and why?
What do you feel needs to happen for you to get better?
Should be Empty:

Functional Gastro Female Intake Questionnaire

General Information

Allergies

Lifestyle Review

Sleep

Exercise

Nutrition

Women's History

Gynecological Screening/Procedures:

Family History

Medical History: Illnesses/Conditions

Medication/Supplements

Readiness Assessment