Follow-up Questionnaire
Name
*
First Name
Last Name
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your current weight?
LBS
Please select any tests you have performed since your last appointment:
Blood Tests
Functional Medicine Test Kits
Other
Please list the names of the test kits that you have performed since your last appointment:
We will make every effort to obtain your results prior to the appointment, but we strongly recommend uploading a copy of any pertinent test results or documents related to the visit. PLEASE NOTE: If you had Function Health results, you MUST upload them here or e-mail a copy to our office. We cannot access these results electronically.
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What are your top concerns to discuss during your follow-up appointment?
Do you have any new allergies?
Please list all prescription medications, vitamins & dietary supplements:
Rows
Medication Name
Strength/Dose
Frequency
Start date
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Medical Symptoms Questionnaire (MSQ)
The MSQ identifies symptoms that help to determine the underlying causes of illness, and helps you track your progress over time. If you are completing this questionnaire for the FIRST time, please record your symptoms over the last 48 hours. If you have completed this questionnaire with us previously, please rate your symptoms from the last 30 days.
HEAD
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia
HEAD TOTAL
EYES
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Watery/Itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
EYES TOTAL
EARS
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss
EARS TOTAL
NOSE
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation
NOSE TOTAL
MOUTH/THROAT
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
MOUTH/THROAT TOTAL
SKIN
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
SKIN TOTAL
HEART
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
HEART TOTAL
LUNGS
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
LUNGS TOTAL
DIGESTIVE TRACT
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
DIGESTIVE TRACT TOTAL
JOINTS/MUSCLE
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles
JOINTS/MUSCLE TOTATL
WEIGHT
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating
WEIGHT TOTAL
ENERGY/ACTIVITY
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
ENERGY/ACTIVITY TOTAL
MIND
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination
MIND TOTAL
EMOTIONS
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
EMOTIONS TOTAL
OTHER
Rows
0-Never/almost never have the symptom
1-Occasionally, not severe
2-Occasionally, severe
3-Frequently, not severe
4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge
OTHER TOTAL
GRAND TOTAL
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Promis
The Patient-Reported Outcomes Measurement Information Systems (PROMIS®) can be used to measure health symptoms and health-related quality of life domains such as pain, fatigue, depression, and physical function, which are relevant to a variety of chronic diseases.
Physical Function
Rows
Without any difficulty
With a little difficulty
With some difficulty
With much difficulty
Unable to do
Are you able to do chores such as vacuuming or yard work?
Are you able to go up and down stairs at a normal pace?
Are you able to go for a walk of at least 15 minutes?
Are you able to run errands and shop?
Anxiety: In the last seven days...
Rows
Never
Rarely
Sometimes
Often
Always
I felt fearful
I found it hard to focus on anything other than my anxiety
My worries overwhelmed me
I felt uneasy
Depression: In the last seven days...
Rows
Never
Rarely
Sometimes
Often
Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless
Fatigue: During the last seven days...
Rows
Not at all
A little Bit
Somewhat
Quite a bit
Very much
I feel fatigued
I have trouble starting things because I am tired
How run-down did you feel on average?
How fatigued were you on average?
Sleep Disturbance: In the past 7 days…
Rows
Very poor
Poor
Fair
Good
Very good
My sleep quality was
Sleep Disturbance: In the past 7 days...
Rows
Not at all
A little bit
Somewhat
Quite a bit
Very much
My sleep was refreshing
I had a problem with my sleep
I had difficulty falling asleep
Ability to Participate in Social Roles and Activities
Rows
Never
Rarely
Sometimes
Usually
Always
I have trouble doing all of my regular leisure activities with others
I have trouble doing all of the family activities that I want to do
I have trouble doing all of my usual work (include work at home)
I have trouble doing all of the activities with friends that I want to do .
Pain Interference: In the past 7 days…
Rows
Not at all
A little bit
Somewhat
Quite a bit
Very much
How much did pain interfere with your day to day activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to participate in social activities?
How much did pain interfere with your household chores?
Rate your pain from 0 (no pain) to 10 (worst pain imaginable):
Rows
0
1
2
3
4
5
6
7
8
9
10
Pain
PROMIS Score:
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