• Health Questionnaire

  • Please read the enclosed instructions carefully and fill out the questionnaire with as much information as you can.

    Failure to complete the MSQ may result in your appointment being rescheduled. 

  • GENERAL INFORMATION

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  • Gender*
  • Genetic Background*
  • Highest Education Level
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Physician

  • Format: (000) 000-0000.
  • Referred by

  • PHARMACY INFORMATION

  • Primary pharmacy

  • Format: (000) 000-0000.

  • Compounding/Supplement pharmacy

  • Format: (000) 000-0000.

  • MEDICAL QUESTIONNAIRE

  • COMPLAINTS/ CONCERNS

  • Please list current and ongoing problems in order of priority:

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  • MEDICAL HISTORY

  • DISEASES/ DIAGNOSIS/ CONDITIONS

    Check appropriate box and provide date of onset
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  • PREVENTIVE TESTS AND DATE OF LAST TEST

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  • INJURIES

  • Check box if yes

  • SURGERIES

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  • BLOOD TYPE

  • GYNECOLOGIC HISTORY

    (for women only)

  • OBSTETRIC HISTORY

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  • MENSTRUAL HISTORY

  • Pain
  • Clotting
  • Has your period ever skipped?
  • Use of hormonal contraception such as:
  • Do you use contraception?
  • WOMEN'S DISORDERS/HORMONAL IMBALANCES
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  • Results:
  • Are you in menopause?

  • MEN'S HISTORY

    For men only
  • Have you had a PSA done?
  • PSA level:

  • GI HISTORY

  • Foreign Travel?*
  • Wilderness Camping?*
  • Have you ever had severe:
  • Do you feel like you digest your food well?
  • Do you get bloated after meals? *

  • PATIENT BIRTH HISTORY

  • Age at introduction of: 

  • Did you eat a lot of candy or sugar as a child?

  • DENTAL HISTORY

  • DENTAL SURGERIES
  • Do you floss regularly?*

  • MEDICATIONS

  • Are you currently taking any medications?*
  • Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc), Motrin, Aspirin?
  • Have you had prolonged or regular use of Tylenol?
  • Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec, etc.)?
  • Frequent antibiotics
  • Long term antibiotics
  • Use of steroids (prednisone, nasal allergy inhalers) in the past
  • Use of oral contraceptives

  • FAMILY HISTORY

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  • SOCIAL HISTORY

  • NUTRITION HISTORY

  • Have you ever had a nutrition consultation?*
  • Have you made any changes in your eating habits because of your health?*
  • Do you currently follow a special diet or nutritional program?*
  • Select all that apply:*
  • Weight Fluctuations (> 10 lbs.)
  • How often do you weigh yourself?*
  • Have you ever had your metabolism (resting metabolic rate) checked?*
  • Do you avoid any particular foods?*
  • Do you grocery shop?*
  • Do you read food labels?*
  • Do you cook?*
  • How many meals do you eat out per week?*
  • Select all the factors that apply to your current lifestyle and eating habits:

  • SMOKING

  • Currently Smoking?*

  • Previous Smoking:

  • ALCOHOL INTAKE

  • How many drinks currently per week? 1 drink = 5 ounces wine, 12 oz beer, 1.5 ounces spirits

  • If "None," skip to Other Substances Previous

  • Previous alcohol intake?
  • If yes
  • Have you ever been told you should cut down your alcohol intake?
  • Do you get annoyed when people ask you about your drinking?
  • Do you ever feel guilty about your alcohol consumption?
  • Do you ever take an eye-opener?
  • Do you notice a tolerance to alcohol (can you "hold" more than others)?
  • Have you ever been unable to remember what you did during a drinking episode?
  • Do you get into arguments or physical fights when you have been drinking?
  • Have you ever been arrested or hospitalized because of drinking?
  • Have you ever thought about getting help to control or stop your drinking?

  • OTHER SUBSTANCES

  • Caffeine intake:
  • Cups/day:
  • A day
  • Caffeinated Sodas or Diet Sodas Intake:
  • 12-ounce can/bottle/day
  • Are you currently using any recreational drugs?
  • Have you ever used IV or inhaled recreational drugs?

  • EXERCISE

  • Rows
  • Rate your level of motivation for including exercise in your life?
  • Do you feel unusually fatigued after exercise?
  • Do you usually sweat when exercising?

  • PSYCHOSOCIAL

  • Do you feel significantly less vital than you did a year ago?
  • Are you happy?
  • Do you feel your life has meaning and purpose?
  • Do you believe stress is presently reducing the quality of your life?
  • Do you like the work you do?
  • Have you ever experienced major losses in your life?
  • Do you spend the majority of your time and money to fulfill responsibilities and obligations?
  • Would you describe your experience as a child in your family as happy and secure?

  • STRESS/COPING

  • Have you ever sought counseling?
  • Are you currently in therapy?
  • Do you feel you have an excessive amount of stress in your life?
  • Do you feel you can easily handle the stress in your life?

  • Daily Stressors: Rate on scale of 1-10

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  • Do you practice meditation or relaxation technique?
  • Check all that apply:
  • Have you ever been abused, a victim of a crime, or experienced a significant trauma?

  • SLEEP/REST

  • Average number of hours you sleep per night:
  • Do you have trouble falling asleep?
  • Do you feel rested upon awakening?
  • Do you have problems with insomnia?
  • Do you snore?
  • Do you use sleeping aids?

  • ROLES/RELATIONSHIP

  • Marital status:
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  • Who is living in Household?

  • Resources for emotional support? Select all that apply:
  • Are you satisfied with your sex life?
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  • ENVIRONMENTAL AND DETOXIFICATION ASSESMENT

  • Do you have known adverse food reactions or sensitivities?
  • Do you have any food allergies or sensitivities?
  • Do you have an adverse reaction to caffeine?
  • When you drink caffeine do you feel:
  • Do you adversely react to: Check all that apply:
  • Which of these significantly affect you? Select all that apply:
  • In your work or home environment, are you exposed to:
  • Have you ever turned yellow (jaundiced)?
  • Have you ever been told you have Gilbert's syndrome or a liver disorder?
  • Do you have a known history of significant exposure to any harmful chemicals such as the following:
  • Do you dry clean your clothes frequently?
  • Do you or have you lived or worked in a damp or moldy environment or had other mold exposures?
  • Do you have any pets or farm animals?

  • SYMPTOM PREVIEW

  • GENERAL
  • HEAD, EYES & EARS
  • MUSCULOSKELETAL
  • Muscle Twitches:
  • MOOD/NERVES
  • MOOD/NERVES: Difficulty
  • EATING
  • DIGESTION
  • DIGESTION: Bloating Off
  • DIGESTION: Intolerance to
  • SKIN PROBLEMS
  • ITCHING SKIN
  • SKIN DRYNESS OF
  • LYMPH NODES
  • NAILS
  • RESPIRATORY
  • CARDIOVASCULAR
  • URINARY
  • MALE REPRODUCTIVE
  • FEMALE REPRODUCTIVE
  • FEMALE REPRODUCTIVE: Menstrual
  • FEMALE REPRODUCTIVE: Premenstrual

  • READINESS ASSESSMENT

  • Rate on a scale of: 5 (Very willing) to 1 (Not willing).

     

    In order to improve your health, how willing you are:

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  • Rate on a scale of: 5 (Very confident) to 1(Not confident at all)

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  • Rate on a scale of: 5 (Very supportive) to 1 (Very unsupportive)

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  • Rate on a scale of: 5 (Very frequent contact) to 1 (Very infrequent contact)

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  • 3-DAY DIET DIARY INSTRUCTIONS

  • It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.

    • Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
    • Record information as soon as possible after the food has been consumed.
    • Describe the food or beverage as accurately as possible e.g., milk - what kind?
      (whole, 2% non-fat); toast (whole, wheat,white,buttered);chicken - (fried, baked,breaded), coffee - (decaffeinated with sugar  with 1/2&1/2) 
    • Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
    • Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
    • Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
    • Include any additional comments about your eating habits on this form (ex. craving sweet,
      skipped meal and why, when the meal was at a restaurant, etc).
    • Please note all bowel movements and their consistency (regular, loose, firm, etc.)

  • DIET DIARY

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  • Should be Empty: