Aruka Medical Questionnaire
Please read carefully and answer
Patient Personal Data
Name
*
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Current Physicians
Medical Doctor, NP, Attending Practioner
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Surgeon
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Current Health Concerns
Please Rank Current and Ongoing Health Concerns in Order of Priority
Describe the Problem - Prior Treatment/ Approach
Describe the Problem - Prior Treatment/ Approach
Describe the Problem - Prior Treatment/ Approach
Basic Medical Information
Weight
Height
Waist Circumference (Belt Size or measure around waist at umbilicus)
Average Blood Pressure if you happen to know it
Do you drink alcohol? If so, how many times a week?
Do you smoke? If yes, how many times a day?
Are You Taking any medications on regular or occasional basis?
Yes
No
If you answered YES, please list all medications and dosage you take regularly.
Please list all medications you are allergic to:
Women's Health
Are you pregnant?
Yes
No
How many viable pregnancies have you had?
Did you experience any complications during or after pregnancies? If yes explain.
Have you had or have issues with menstrual cycle (cramping, excessive bleeding, other problems?
Use or problems with hormonal birth control? If so explain.
Are you in menopause? If yes, age of last cycle.
OTHER GYNECOLOGICAL SYMPTOMS. Please check all that apply.
Endometriosis
Ovarian Cysts
Infertility
Fibroids
Fibrocystic Breats
Pelvic Inflammatory Disease
STD
Reproductive Cancer
Other
Men's Health
Check if apply
Testicular Mass
Premature Ejaculation
Prostate Enlargement
Testicular Pain
Difficulty Obtaining Erection
Difficulty Maintaining Erection
Prostate Infection
Loss of Urine Control
Nocturia
Change in Libido
Urinary Stream Issues
Impotence
Vasectomy
STD
Last PSA if known:
Family Health
Please list any medical problems that run in your family ( e.g. diabetes, cancer, heart disease, etc. ) Please state condition and relation to you. For example: Mother / Heart Attack )
Medical History
Check what applies
Gastrointestinal
IBS
GERD
Crohn's Disease/Ulcerative Colitis
Peptic Ulcer Disease
Celiac Disease
Gallstones
SIBO
Other
Respiratory
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep Apnea
Other
Urinary/Genital
Kidney Stones
Gout
Interstitial Cystitis
Frequent Yeast Infections
Sexual Dysfunction
STD's
Other
Musculoskeletal
Fibromyalgia
Osteoarthritis
Chronic Pain
Other
Skin
Eczema
Psoriasis
Acne
Skin Cancer
Other
Cardiovascular
Angina
Heart Attack
Heart Failure
Hypertension (High Blood Pressure)
Stroke
High Blood Fats
Rheumatic Fever
Arrythmia (Irregular Heart Beat)
Murmur
Other
Endocrine/Metabolic
Diabetes 1
Diabetes 2
Hypothyroidism ( Low Thyroid)
Hyperthyroidism (High Thyroid)
Polycystic Ovarian Syndrome
Infertility
Metabolic Syndrome/Insulin Resistance
Hypoglycemia
Inflammatory/Immune
Rheumatoid Arthritis
Chronic Fatigue Syndrome
Food Allergies
Multiple Chemical Sensitivities
Autoimmune Disease
Immune Deficiency
Mononucleosis
Hepatitis
Other
Neurological/Emotional
Epilepsy/Seizures
ADD/ADHD
Headaches
Migraines
Depression
Anxiety
Autism
Multiple Sclerosis
Parkinson's Disease
Dementia
Other
Cancer
Lung
Breast
Colon
Ovarian
Skin
Other
List any INJURIES (ex. concussions, head injuries, broken bones etc. ) and date they occurred.
List any SURGERIES and date they occurred:
Current Symptoms Review
Answer the following questions on a scale of "O" (least/never/zero symptoms), "1" (minor, mild, rarely, monthly), "2" (moderate, occasionally, weekly), to "3" (most, severe, frequently, daily). Take your time and be honest with the answers; the more accurate you the better your will understand which systems are a priority for you.
SCORE 1
Rows
0
1
2
3
Crave sweets and/or carbohydrates
Crave sweets after meals
Frequent thirst
Feel tired after meals
Blurred vision
TOTAL 1
SCORE 2
Rows
0
1
2
3
Shaky and Irritable between meals
Eating energizes me and/or relieves fatigue
Often wake up during the night
Fatigue, fuzzy thinking, headaches between meals
Anxiety and palpitations
TOTAL 2
SCORE 3
Rows
0
1
2
3
Bleeding gums or nosebleeds, or easily bruised
Muscle fatigue or excessive soreness after exercise
Tingling ln hands or feet, and/or cracks In the corners of the mouth
Restless legs and/or muscle cramping/ twitching
Dry/scaly skin and/or bumps on the back of the arms
TOTAL 3
SCORE 4
Rows
0
1
2
3
Feel tired, fatigued, or weak
Experience shortness of breath
Coldness ln hands and feet, or "poor clrrulatlon"
Experience a rapid, or irregular, heart beat
Dizziness or lightheadedness
TOTAL 4
SCORE 5
Rows
0
1
2
3
Anxiety, moodiness, irritability
Negativism, combativeness
Fatigue, weakness, daydreaming
Confusion, Impaired judgement
Fasting Is difficult and uncomfortable
TOTAL 5
SCORE 6
Rows
0
1
2
3
GI symptoms (diarrhea, constipation, heart burn, digestive enzyme)
Musculoskeletal symptoms (exercise intolerance, weakness, cramping)
Neurological symptoms (mood, migraines, balance coordination)
Sensory symptoms (visual, hearing)
Generailzed fatigue or easy to fatigue
TOTAL 6
SCORE 7
Rows
0
1
2
3
Bloating shortly after a meal
Experience heartburn, or use antacids
Excessive belching or burping
Sensitive to a number of foods
Indigestion or nausea after eating
TOTAL 7
SCORE 8
Rows
0
1
2
3
Excessive and/or foul-smelling gas
Lower abdominal bloating relieved by gas
Constipation, diarrhea, both (circle which apply)
History of antibiotic use
History of laxative use
TOTAL 8
SCORE 9
Rows
0
1
2
3
Nausea or diarrhea from high-fat foods
"Greasy" stool that tends to float
Sensitive to caffeine, alcohol, and/or other synthetic chemicals
General itchiness, or itchy palms
Gallbladder removed Yes (3) No (0)
TOTAL 9
SCORE 10
Rows
0
1
2
3
Sensitive to the smell of gasoline, paint, cleaning products, perfumes, or other fragrances
Live, or work.near, heavy traffic, industrial plants, farms, or electricity, or cell phone, towers
Chronic airways issues including nasal congestion, mucous production, or throat or nasal irritation
Chronic headaches, muscle or joint stiffness or pain, or skin issues
Exposure to chemicals, i.e. synthetic fabrics, tap water, cosmetics, cleaning products, and processed foods
TOTAL 10
SCORE 11
Rows
0
1
2
3
Less than 6 hours of sleep a night, disrupted sleep, or sleep at abnormal hours
Routinely consume canola, com or safflower oil
Experience chronic psychological stress
Physical inactivity
Have ever been diagnosed with elevated iron
TOTAL 11
SCORE 12
Rows
0
1
2
3
Joint pain and swelling
Skin problems, rashes
Sudden onset of symptoms, which have progressively worsened over time
Swollen glands and/or sore, achy muscles
Family history of autoimmunity
TOTAL 12
SCORE 13
Rows
0
1
2
3
Chronic pain and/or lasting fatigue
Unrefreshing sleep
Extreme fatigue after exertion
Persistent mental/emotional challenges
Frequent headaches and/or pain
TOTAL 13
SCORE 14
Rows
0
1
2
3
Constipation, diarrhea, gas, or IBS
Difficulty falling asleep or staying asleep
Skin irritations, rash, hives, eczema
Often hungry or unsatisfied after meals
History of allergies and/or asthma
TOTAL 14
SCORE 15
Rows
0
1
2
3
Red, itchy, or flaky skin
Visual changes
Headaches, "spaciness", or neurological deficits
History of antibiotic use
History of jock itch, athlete's foot, toe nail fungus, or other yeast infection
TOTAL 15
SCORE 16
Rows
0
1
2
3
Difficult time getting going in the morning
Difficulty falling asleep, a "night person"
Feel "tired and wired"
Perspire easily, even with minimal activity
Elevated blood pressure
TOTAL 16
SCORE 17
Rows
0
1
2
3
Crave salt or liberally salt food
Lightheaded when standing up quickly
Difficulty staying asleep
Low blood pressure
Fatigue and/or depression
TOTAL 17
SCORE 18
Rows
0
1
2
3
Tendency to be cold, especially hands and feet
Difficulty losing weight
Low energy, or tired all the time
Brain fog, mental sluggishness
Dry skin, brittle nails, hair loss
TOTAL 18
SCORE 19
Males Only
Rows
0
1
2
3
Decreased libido
Decrease in morning erection or strength in erection
Decreased enjoyment in life
Decreased strength and/or endurance
Difficulty in building or maintaining muscle
TOTAL 19
SCORE 20
Females Only
Menstruating
Rows
0
1
2
3
Acne and/or unwanted facial hair growth
Abnormal menstruation (heavy, extended, shortened, scanty)
Pain, cramping, and/or breast tenderness during menses
Significant mood changes during menses
Currently taking, or history of taking birth control
TOTAL 20
SCORE 21
Females Only
Menopausal
Rows
0
1
2
3
Experience hot flashes
Acne and/or unwanted facial hair growth
Mood swings, depression, night sweats
Vaginal thinning, dryness, or itchiness
Low libido
TOTAL 21
SCORE 22
Rows
0
1
2
3
Lack of motivation
Feelings of worthlessness or selfdestructive thoughts
Quick to anger or frustration
Inattentive, poor circulation, disorganized thinking
Decreased pleasure in life
TOTAL 22
SCORE 23
Rows
0
1
2
3
Loss of enjoyment in favorite activities, or relationships
Feelings of depression and sadness
Gut distress and/or decreased pain tolerance
Feelings of overwhelm, or obsessive thoughts
Lack of deep, restful sleep
TOTAL 23
SCORE 24
Rows
0
1
2
3
Feelings of anxiety, panic or inner tension
Experience restlessness, mentally or physically
Easily worried
Feel easily overwhelmed and overworked
Insomnia or difficulty sleeping
TOTAL 24
SCORE 25
Rows
0
1
2
3
Rapid or shallow breathing
Rapid heart rate
Fatigue
Headaches
Lack of appetite
TOTAL 25
SCORE 26
Rows
0
1
2
3
Lightheadedness
Muscle twitching. spasm, or cramps
Numbness or tingling in face/hands/feet
Tremors, especially in hands
Slow respiration or breathing rate
TOTAL 26
SCORE 27
Rows
0
1
2
3
I don't drink water between meals
Urinate frequently
Loose or watery stools
Excessively salty sweat
Frequent thirst
TOTAL 27
SCORE 28
Rows
0
1
2
3
I feel as if nobody understands me
It is difficult for me to make friends
People are around me, but not with me
My social relationships are superficial
No one really knows me well
TOTAL 28
SCORE 29
Rows
0
1
2
3
I feel in control of my life
Life is rewarding, I am optimistic about the future
I am satisfied with my life
I feel healthy, attractive, and am pleased with who I am
I find beauty and joy in things, and laugh often
TOTAL 29
SCORE 30
Rows
0
1
2
3
I can easily, succinctly articulate my purpose in life
I have discovered who I really am
I get intensely involved in, and feel greatly fulfilled by, many of the things I do each day
My life is centered around a set of core beliefs that give meaning to my life
It is more important that I enjoywhat I do, rather than if people are impressed by it
TOTAL 30
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