Functional Gastro Male Intake Questionnaire

Functional Medicine Male 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)
Please enter a valid phone number.
(Work)
Please enter a valid phone number.
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)
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
How did you hear about our practice?

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

Please rank current and ongoing health concerns in order of priority

	Describe Problem	Severity	Satisfied	Any thoughts?
1
2
3
4
5
6

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
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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 sleeping aids?

Exercise
If you use sleeping aids, explain

Current Exercise Program

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

Do you feel motivated to exercise?

Yes A little No
Are there any problems that limit exercise?

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

No Yes
If yes, explain
Nutrition
Do you currently follow any of the following special diets or nutritional programs? (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
Type a question

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)

Monosodium glutamate (MSG) Artificial Sweeteners Garlic/onion Cheese Monosodium glutamate (MSG) Chocolate Alcohol Red wine Sulfite-containing foods (wine, dried fruit, salad bars) Preservatives Other food substances: 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
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 healthy foods
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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?

Yes (if yes, please pleasewith the next 3 questions) No
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
Smoking
Do you smoke currently?

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

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

Yes No
If yes, using what methods

If you previously smoked:


Packs/day
# of years

Are you regularly exposed to second-hand smoke?

Yes No
Alcohol
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 No
If yes, describe your intake

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
Other Substances
Are you currently using any recreational drugs?

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

Yes No
Stress
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?
Which techniques do you use? (Check all that apply)

Meditation Breathing Tai Chi Yoga Prayer 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?
Relationships
Marital status

Single Married Divorced Gay/Lesbian Long-Term Partner Widow/er
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, describe your support:

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? (On scale of 1-10, or N/A if not applicable)

	N/A	Rating
Overall
At School
In your job
In your social life
With close friends
With sex
With your attitude
With boyfriend/girlfriend
With your children
With your parents
In your spouse

History

Patient's Birth/Childhood History:
You were born

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

Yes No
If yes, explain

You were:

	Select all that apply	How long?
Breast-fed
Bottle-fed
Don't Know

Age of introduction of:

	Age?
Solid food:
Wheat
Dairy

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

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

Yes No
Dental History
Check if you have any of the following:

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

Yes NoIf yes, when:
If yes, when
How many fillings did you have as a kid?
Do you brush regularly

Yes No
Do you floss regularly?

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

Cigarette smoke Perfume/colognes Auto exhaust fumes Other
In your work or home environment are you regularly exposed to : (check all that apply)

Mold Water leaks Renovations Chemicals Electromagnetic radiation Damp environments Carpets or rugs Stagnant or stuff air Smokers Pesticides Herbicides Harsh chemicals (solvents, glues, gas, acids, etc) Cleaning chemicals Heavy metal (lead, mercury, etc.) Paints Airplane travel Other
Do you have any significant exposure to any harmful chemicals?

Yes No
If yes, chemical name, length of exposure, Date
Do you have any pets or farm animals?

Yes No
If yes, do they live

Inside Outside Both inside and outside
Men's History
(Check box if applicable)

Testicular mass Testicular pain Prostate enlargement Prostate infection Change in sex drive Impotence Premature ejaculation Difficulty obtaining an erection Difficulty maintaining an erection Loss of control of urine Urinary urgency/hesitancy/change in stream Vasectomy Nocturia (urination at night) Sexually transmitted diseases
Screens/Procedures: (If applicable, provide date)
Last PSA test
PSA Level

0-2 2-4 4-10 >10
Other tests/procedures (list type and dates)

Month Day Year
Date
Family History

Check family members that have/had any of the following

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

Gastrointestinal

	Yes	Past
Irritable bowel syndrome
GERD (reflux)
Crohn’s disease/ulcerative colitis
Peptic ulcer disease
Celiac disease
Gallstones
Other:

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Medical History: Illnesses/Conditions (Check YES = condition you currently have, Check PAST = a condition you've had in the past)

Respiratory

	Yes	Past
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep apnea
Other:

Urinary/Genital

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

Endocrine/Metabolic

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

Inflammatory/Immune

	Yes	Past
Rheumatoid arthritis
Chronic fatigue syndrome
Food allergies
Environmental 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
Prostate
Skin
Other:

Medical History

	Date	Comments
Bone density
CT scan
Colonoscopy
Cardiac stress test
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	Reasons
1
2
3

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

Musculoskeletal

	Mild	Moderate	Severe
Back muscle spasm
Calf cramps
Chest tightness
Foot cramps
Joint deformity
Joint Paint
Joint redness
Joint stiffness
Muscle pain
Muscle spasm
Muscle stiffness
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
Auditory hallucinations
Blackouts
Depression
Difficulty in concetrating
Difficulty with balance
Difficulty with thinking
Difficulty with judment
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
Heart attack
Heart murmur
High blood pressure
Irregular pulse
Mitral valve prolapse
Palpitations
Phlebitis
Swollen ankles/feet
Varicose veins

Current medications (include prescription and over-the-counter)

Nutritional supplements (vitamins/minerals/herbs etc

Urinary

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

Digestion

	Mild	Moderate	Severe
Anal spasms
Bad teeth
Bleeding gums
Bloating
Blood in stool
Burping
Canker sores
Cold sores
Constipation
Cracker at coner of lips
Dentures w/ poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Farting
Fissures
Reflux
Heartburn
Hemorriholds
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
Periodontal disease
Sore tongue
Strong stool odorEsting
Undigested food in stools
Upper abdominal pain
Vomiting

Eating

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

Respiratory

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

Nails

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

Lymph Nodes

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

Skin, Dryness of:

	Mild	Moderate	Severe
Eyes
Feet- cracking
Feet - peeling
Hair
Hands - cracking
Hands - peeling
Mouth/throat
Scalp
Skin in general

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

Male Reproductive

	Mild	Moderate	Severe
Discharge from penis
Ejaculation problem
Genital pain
Impotence
Infection
Lumps in testicles
Poor libido (low sex drive)

Medications/Supplements
Current medications (include prescriptions and over-the-counter) Name/Dosage/Start Date (mo/yr)/Reason for use
Nutritional supplements (vitamin/mineral/herbs etc.) Medication Name/Dosage/Start Date (mo/yr)/Reason for use
Have medication 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, prednisione, etc.)?

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

Readiness Assessment and Health Goals

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, deep habits)
Practice relaxation techniques
Engage in regular exercise

How confident are you of your ability to organize and follow through on th above health-related activities ( 5= very confident; 1 = not confident at all).

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

5 4 3 2 1
How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your peron healt prgram? ( 5 = very frequent; 1 = very infrequent contact):

5 4 3 2 1
Comments
Health Goals
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 Medicine Male Intake Questionnaire

General Information

Current Health Concerns

Lifestyle Review

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History

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Medications/Supplements

Readiness Assessment and Health Goals