INTAKE FORM Part 2
Thermography Center of Dallas/ Dallas Wellness and Thermography Center
PATIENT HEALTH HISTORY
Answer the following questions to the best of your ability. All Fields are required.
Name:
*
First Name
Last Name
MERCURY
Please select YES or NO
*
YES
NO
Do you have amalgam (silver) fillings in your teeth?
Have you ever had an amalgam removed?
If you had amalgams removed, was it done by a biological dentist using a safe protocol?
Did your mother have amalgam when pregnant with you?
Have you ever worked in a dental office?
Have you had any dental crowns?
Have you had any bridges?
Have you had any root canals?
Have you had any tooth extractions?
Do you have any dental implants, retainers or other metal in your mouth?
Did you wear contact lenses during the 1980’s or early 1990’s?
Did you take oral contraceptives during the 1980’s or early 1990’s?
Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?
Have you noticed any adverse reactions to these shots?
Do you have any tattoos with red ink?
Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?
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LEAD
Please select YES or NO
*
YES
NO
Does your occupation involve soldering or metal salvage?
Have you done any old home repair or sandblasting?
Do you do a lot of painting?
Was your home built before 1978?
Have you ever worn cosmetics containing kohl? (make-up
with dark black or deep red pigment)
Are you around a lot of fake leather, or vinyl?
Do you get stomach aches in the morning?
GENERAL TOXICITY
Please select YES or NO
*
YES
NO
Have you ever lived near, on or by a golf course, freeway or tension wires?
Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)
Do you have your house sprayed with pesticides for pest control?
Do you spray herbicide (weed killers) in or around your home?
Do you use conventional insect repellants on your self or family?
Do you use conventional sunscreen?
Do you use conventional perfume or cologne every day?
Do you get your hair colored? If so, is it on the scalp?
Do you use aerosol hairspray?
Do you get your nails done?
Do you use air freshener in your house, work or car?
Do you drink filtered water?
Do you drink bottle water?
Do you have a water filtration system for your entire house or shower filtration?
Does your spouse or other family members work around chemicals?
MOLD
How old is the house you are living in?
*
How long have you lived there?
*
Have you noticed any new symptoms since moving in?_________ If so, what?
*
Please select YES or NO
*
YES
NO
Do you see mold growing at home, work or school?
Have you ever had water damage at home, work or school?
Does your home, workplace or school have a damp or mildew smell?
Does spending time in your basement cause or worsen your symptoms?
Does your basement ever get wet?
Do you have a crawl space?
Does your basement or crawl space have a sump pump?
Does spending time in a different location for at least a few days cause
a noticeable decrease in your symptoms?
Does your car have a mildew smell?
Does anyone in your home have asthma like symptoms?
Does anyone in your family have chronic sinus infections or irritations?
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LYME DISEASE
Please select YES or NO
*
YES
NO
Have you ever been diagnosed with Lyme Disease?
Have you had dry sockets or infected tooth extractions?
Have you ever been bitten by a tick or recluse spider?
Have you ever seen a bulls-eye rash appear on any part of your body?
Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?
Was your mother ever diagnosed with Lyme Disease?
Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis
(MS), or an Autoimmune condition?
Do you frequently go camping, hunting or are you involved in outdoor
activities (specifically in wooded or grassy areas)?
HEALTH HISTORY
Please select YES or NO
*
YES
NO
Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?
Does anyone in your family experience similar symptoms to yours?
Do you have any history of kidney dysfunction?
Do you or any immediate family member have a history with cancer?
Do you have any history of heart disease, myocardial infarction (heart attack), etc.?
Are you currently having any thoughts of suicide?
Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?
Do you have a history of strokes?
Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?
Have you ever been in an auto accident, fallen or received a major physical injury?
Are you in menopause?
MICROBIOME HEALTH
Please select YES or NO
*
YES
NO
Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, Brussels sprouts or other vegetables?
Do you often have gas that has a sulfur or foul smell?
Are you sensitive to supplements?
Have you ever been vegan or vegetarian for any length of time?
Can you tolerate Meat?
Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?
Have you taken birth control or Hormone replacement therapy for any length of time?
If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?
Have been on antibiotics for any extended period of time or often as a child or adult?
Were you caesarian delivered?
Were you breast fed?
Does your gut temporarily feel better after a round of antibiotics?
Do you have 1 to 2 bowel movements a day?
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HEALTH PROFILE
Please select only one point scale per criteria
*
0
1
2
3
4
Anxiety
Mood swings
Enraged behavior or anger for no reason
Excessive shyness, timidity, social phobia (not typical to your personality)
Irritability (not typical to your personality)
Low body temperature (below 97.5o)
Insomnia (can’t get to sleep or return to sleep)
Dizziness
Sound in ears (ringing or hearing your heart beat)
Psychological symptoms, even thoughts of suicide
Sensitivity to sound
Indecisiveness
Feeling of being overwhelmed or fearful
Metallic taste in your mouth
Bad breath
Bleeding gums
Sensitive teeth
Canker sores or other sores in the mouth
Floaters, shadows or swimmers when you read or look into the sky
Dyslexia or loss of place while reading, even as a child
Swelling eyelids
Peeling on top layer of skin (hands, feet)
Dry skin
Heart pain (angina) and you are under 45 years old
Depression
Gout (arthritic pain, especially in big toes)
Pain in shoulders or upper back
Twitching eyelids
Anemia (low iron/hemoglobin on blood test)
Wrist/ankle drop or weak extensor muscles
Hair falls out (not normal male pattern baldness)
Sensitivity to light
Fatigue after exercising (feeling worse)
Bad night vision or seeing halos around lights
Shortness of breath, with very little effort
Excessive thirst and/or frequent urination
Red eyes or tearing
Blurred vision at times
Morning stiffness
Sensitivity to smells, including chemicals such as
petrochemicals, perfumes, air fresheners
Chronic fatigue or weakness
Non-restful sleep
Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)
Trouble processing new information
Word reversal or trouble finding words
Sensitivity to touch
Short-term memory loss
Chronic sinus congestion
Dry non-productive cough
Muscle twitching
Excessive sweating, especially at night
Joint pain-not necessarily true arthritis-can move from joint to joint
Difficulty losing weight regardless of diet or exercise
Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis
Frequent illness, prolonged illness or sick days
Numbness or weakness in arms and legs
Headaches
Trouble adding or dividing numbers in your head
Fluctuating constipation and diarrhea
Stomach pain for no apparent reason
Appetite swings
Frequent muscle aches, cramps, unusual sharp sudden pains
Rashes or rosacea
Cold extremities (hands and feet)
Submit
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