• 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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  • Emergency Contact

  • Physician

  • PHARMACY INFORMATION

  • Primary pharmacy

  • Compounding/Supplement pharmacy

  • 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

  • SURGERIES

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  • GYNECOLOGIC HISTORY

    (for women only)

  • OBSTETRIC HISTORY

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  • MENSTRUAL HISTORY

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  • MEN'S HISTORY

    For men only

  • GI HISTORY

  • PATIENT BIRTH HISTORY

  • Age at introduction of: 

  • DENTAL HISTORY

  • MEDICATIONS

  • FAMILY HISTORY

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  • SOCIAL HISTORY

  • NUTRITION HISTORY

  • SMOKING

  • Previous Smoking:

  • ALCOHOL INTAKE

  • If "None," skip to Other Substances Previous

  • OTHER SUBSTANCES

  • EXERCISE

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  • PSYCHOSOCIAL

  • STRESS/COPING

  • Daily Stressors: Rate on scale of 1-10

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  • SLEEP/REST

  • ROLES/RELATIONSHIP

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  • Who is living in Household?

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  • ENVIRONMENTAL AND DETOXIFICATION ASSESMENT

  • SYMPTOM PREVIEW

  • 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: