• FM Assessment IFM Questionnaires

    Applicant Health Information
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • IFM MSQ Total Score: {totalMsq}

  • Candida Total Score: {totalScore}

  • Men Women Interpretation
    40 or below  60 or below  Yeast is less apt to cause health problems 
    41-90 61-121 Yeast-connected health problems are possibly present 
    91-140 121-180 Yeast-connected health problems are probably present
    141+ 181+ Yeast-connected health problems are almost certainly present

     

     

     

  • Horowitz/MSIDS 38 Point Symptom Total: {finalScore}

    Scale used by Dr. Horowitz:

    0--20 points:         Tick borne illness not likely
    21--45 points:       Tick borne illness possilbe
    46 points or more: Tick borne illness highly likely
     

  • IFM Medical Symptoms Questionnaire (MSQ)

    (c) 2015 The Institute for Functional Medicine

  •     

  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • Please rate each of the following symptoms based upon your typical health profile for the past 14 days.

    Point Scale

     0  Never or almost never have the symptom
     1  Occasionally have the symptom, effect is not severe
     2  Occasionally have the symptom, effect is severe
     3 Frequently have the symptom, effect is not severe
     4  Frequently have the symptom, effect is severe
  • Head*
    Rows
  • Eyes*
    Rows
  • Ears*
    Rows
  • Nose*
    Rows
  • Mouth/Throat*
    Rows
  • Skin*
    Rows
  • Heart*
    Rows
  • Lungs*
    Rows
  • Digestive Tract*
    Rows
  • Joints/Muscles*
    Rows
  • Weight*
    Rows
  • Energy/Activity*
    Rows
  • Mind*
    Rows
  • Emotions*
    Rows
  • Other*
    Rows
  • {totalMsq}

    Total MSQ Calcuation

  • IFM Candida Screening Questionnaire

    (c) 2015 The Institute for Functional Medicine

  •      

  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

       

  • Answering these questions will help you and your clinician decide if yeast may be contributing to your health problems.

    For each section, read the directions and score as indicated. The score for each section is calculated after each section. The total score is calculated at the end of the form.  

  • Section A: History*
    Rows
  • {sectionA176}

    Section A Score

  • Section B: Major Symptoms*
    Rows
  • {sectionB}

    Section B Score

  • Section C: Other Symptoms*
    Rows
  • {sectionC190}

    Section C Score

  • {totalScore}

    Total Score

  • Horowitz/MSIDS 38 Point Symptom Checklist

    Patient Health Information
  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

  • This is a questionnaire to determine the probability of your having Lyme disease and other tick borne disorders.

     

    Copyright ©Dr. Richard Horowitz, published in “How Can I Get Better: An Action Plan for Treating Resistant Lyme and Chronic Disease.” St. Martin’s Press, 2017. Empirical Validation of the Horowitz Multiple Systemic Infectious Disease Syndrome Questionnaire for Suspected Lyme Disease. Maryalice Citera*, Ph.D., Phyllis R. Freeman2, Ph.D., Richard I. Horowitz2, M.D., International Journal of General
    Medicine 2017:10 249–273. http://www.ncbi.nlm.nih.gov/pubmed/28919803

     

  • Section 1. Think about how you have been feeling over the previous month and how often you have been bothered by the following:*
    Rows
  • {section1}

    Section 1 Score

  • Section 2. Please check off each incident you can answer "yes" to with the following questions:*
    Rows
  • {section2209}

    Section 2 Score

  • Section 3. Thinking about your overall physical health, for how many days during the past 30 days was your physical health not good?*
  • Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good?*
  • {section3215}

    Section 3 Score

  • {finalScore}

    Final Score

  • Brain Region Localization Form

    (c)2019 Datis Kharrazian and the Kharrazian Institute
  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions.

  • Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11 & 12)*
    Rows
  • Frontal lobe Precentral and Supplementary Motor Areas (Areas 4 & 6)*
    Rows
  • Frontal lobe Broca's Motor Speech Area (Areas 44 & 45)*
    Rows
  • Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3, 1, 2 and 7)*
    Rows
  • Parietal Inferior Lobule (Areas 39 and 40)*
    Rows
  • Temporal Lobe Auditory Cortex (Areas 41 and 42)*
    Rows
  • Temporal Lobe Auditory Association Cortex (Area 22)*
    Rows
  • Medial Temporal Lobe Hippacampus*
    Rows
  • Occipital Lobe (Areas 17, 18 and19)*
    Rows
  • Cerebellum--Spinocerebellum*
    Rows
  • Cerebellum--Cerebrocerebellum*
    Rows
  • Cerebellum--Vestibulocerebellum*
    Rows
  • Basal Ganglia Direct Pathway*
    Rows
  • Basal Ganglia Indirect Pathway*
    Rows
  • Autonomic Reduced Parasympathetic Activity*
    Rows
  • Autonomic Increased Sympathetic Activity*
    Rows
  •  {name}  {patientDate180}  {date57}
    Patient Name Date of Birth Date Completed

     

  • Congratulations! You have now reached the end of SFM's Functional Medicine Program New Patient Application. You can review the information saved on the forms by using the "Back" buttom.

    When you are finished with these forms, please select the "Submit" buttom. A copy of the forms will be sent to the provided email. A staff member from Sparks Family Medicine will be in touch. Thank you! 

  • Should be Empty: