New Patient Questionnaire

  • New Patient Questionnaire

  • Please complete this form and return it to us at least 3 days before your scheduled appointment. Be as thorough with your answers as possible. It assists us in identifying root causes and in formulating our treatment plans.

  • Primary Insured DOB
     - -
  • Relationship to the Insured

  • Please provide the contact and mailing information for your insurance carrier.

  • Format: (000) 000-0000.

  • Current History and ATMs

  • Birth History

  • Birth Type
  • Term
  • Breast Fed
  • Were you treated with antibiotics immediately after birth?
  • Were you hospitalized into the NICU after birth?

  • Childhood History

  • Who were you raised by?
  • Did you have a happy childhood?
  • Did you feel safe growing up?
  • Did you have close friendships?
  • Did you attend Daycare?
  • Were you a victim of abuse?
  • Did family members smoke cigarettes?
  • Was there any alcohol or drug abuse in the home?
  • Did you eat a lot of candy/sweets?
  • Where did you spend most of your playtime?
  • Who did you mostly play with?
  • Please check any conditions you experienced in childhood (ages birth to 12)
  • Were you treated with antibiotics more than once per year?
  • Were you treated with corticosteroids (i.e., prednisone) in childhood?

  • Adolescence

  • Were you happy during these years?
  • Did you have close friends?
  • Were you physically active?
  • Did you participate in any sports?
  • Were you a victim of abuse?
  • Did you smoke cigarettes?
  • Did you drink alcohol?
  • Did you ever use recreational drugs?
  • Did you develop any of the following conditions in adolescence?
  • Were you treated with antibiotics more than once per year?
  • Did you require treatment with corticosteroids (i.e., prednisone)?

  • Adulthood

  • Current Tobacco Use?
  • Former Tobacco Use?
  • Alcohol Use?
  • Recreational Drug Use?
  • If you drink alcohol, how many drinks do you have?
  • Please check any medical conditions you have been diagnosed with in adulthood.
  • Have you ever been diagnosed with cancer?
  • Have you been treated with antibiotics more than once per year?
  • Have you needed to be treated with corticosteroids (i.e., prednisone, dexamethasone)
  • Have you ever been diagnosed with thrush or yeast infections?
  • Do you use acid-blocking medications regularly?
  • Do you use NSAIDs (ibuprofen, Aleve, Goody Powder) more than once per week regularly?
  • Do you use acetaminophen (Tylenol) more than once per week regularly?
  • Do you require treatment with opioid pain medications for chronic pain?

  • Symptoms Review

  • General Symptoms
  • Head, Eyes, and Ears
  • Cardiovascular
  • Mood/Nerves
  • GI/Digestion
  • Musculoskeletal
  • Respiratory
  • Urinary
  • Eating
  • Skin

  • Female History (Women Only)

  • Date of Last Period.
     - -
  • Please check any conditions you have been diagnosed with.
  • Have you been treated with oral contraceptives (birth control pills)?
  • Have you been treated with any of the following?
  • Have you had a hysterectomy
  • Have you had a tubal ligation?
  • Have you ever had a lumpectomy?
  • Have you been treated with Bioidentical Hormone Replacement Therapy?
  • Last Pap Smear
     - -
  • Last Mammogram
     - -
  • Have you ever had a Thermogram?
  • Have you ever been diagnosed with a sexually transmitted infection?
  • Please check all that apply to you.

  • Male History (Men Only)

  • Please check any that apply to you (past or present)
  • Have you ever been diagnosed with Testosterone Deficiency?
  • Have you ever been on Testosterone Replacement?
  • Have you ever been diagnosed with a sexually transmitted infection?

  • Immune & Detox

  • Have you ever been bitten by a tick?
  • Have you had chicken pox?
  • Have you ever been diagnosed with Lyme disease?
  • Have you ever been diagnosed with mono?
  • Have you ever developed an acute illness (GI, respiratory) with foreign travel?
  • Have you ever had COVID-19?
  • Are you regularly exposed to any of the following?
  • Have you ever lived near powerlines?
  • Type of water supply in your home
  • Do you drink from plastic bottles?
  • Do you use plastic tupperware or styrofoam?
  • Do you react adversely to chemicals (perfume, paint, etc.)?
  • Do you react adversely to caffeine (headaches, palpitations, anxiety)?
  • Do you use Bluetooth headsets regularly?
  • Dental History: Do you have any of the following?

  • Diet & Nutrition

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  • Have you ever had a dietary or nutrition consultation?
  • Do you eat red meat?
  • Do you eat pork?
  • Do you eat chicken?
  • Do you eat fish?
  • Do you eat shellfish?
  • Do you eat eggs?
  • Do you eat vegetables?
  • Do you eat fruit?
  • Do you eat nuts & seeds?
  • Do you consume dairy (milk, cheese, yogurt)?
  • Have you ever performed an elimination diet?
  • Do you adversely react to any of the following foods?
  • Please check off all diets you have tried at some point.
  • Do you perform intermittent fasting?
  • Please check any of the following you consume more than once per week.
  • Please check all that apply to your current lifestyle and eating habits:
  • Do you drink coffee?
  • Do you drink black/green tea?
  • Do you drink soda?
  • Do you drink herbal tea?
  • Do you eat/drink artificial sweeteners (Splenda, Nutrasweet)? This can include soda, candies, condiments, etc.
  • Do you use natural sweeteners (honey, maple syrup, sugar)?
  • Do you use Natural Non-Glycemic Sweeteners (Stevia, Monk Fruit, Erythritol)?

  • Psycho-Social History

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  • Do you feel generally happy with your life?
  • Do you feel life has meaning and purpose?

  • Please complete the following STRESS Assessment
    0 = No Stress
    3 = Moderate Stress
    5 = High Stress

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  • Do you feel you handle stress easily?
  • Do you feel you have an excessive amount of stress in your life?
  • Check off any of the following that you perform on a regular basis.

  • On a scale from 1-5, please score the quality of the following aspects of your life.
    0 = Poor
    3 = Good
    5 = Great

  •
  • Have you ever been diagnosed with depression?
  • Have you ever been diagnosed with anxiety?
  • Have you ever been hospitalized for a mental health condition?
  • Have you ever attempted suicide?
  • Are you presently attending therapy?
  • Have you attended therapy in the past?
  • Are you interested in a referral to a therapist for stress management support?
  • Do you have a religious or spiritual practice?

  • Activity and Fitness

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  • Do you perform exercise on a weekly basis?
  • Do you have a gym membership?
  • How many days per week do your perform cardio activities?
  • How many days per week do your perform resistance training activities?
  • How long are your cardio sessions?
  • How long are your resistance training sessions?
  • Please check all activities you participate in.
  • Do you have any restrictions or limitations to exercise?
  • Would you be interested in working with a personal trainer?

  • Sleep & Relaxation

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  • Do you fall asleep easily (within 10-15 minutes of going to bed)?
  • If you awaken, do you have a difficult time falling back to sleep?
  • Do you ever take naps?
  • Do you feel rested upon awakening?
  • Do you snore?
  • Do you have Sleep Apnea?
  • Do you use a CPAP?
  • Do any of the following disrupt your sleep?
  • Do you use any of the following for sleep support?

  • Readiness Assessment

  • Please select the most appropriate answer from the following.
    0 = Unwilling
    5 = Moderately willingness
    10 = Very willing

  •

  • Level of Support:
    0 = None
    3 = Moderate
    5 = High

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  • Should be Empty: