Continued…
Oral Health History
How long since you last visited the dentist? What was the reason for that visit?
In the past 12 months has a dentist or hygienist talked to you about your oral health, blood sugar or other health concerns? (explain)
What is your current oral and dental regimen? (Please note whether this regimen is once or twice daily or occasionally and what kind of toothpaste you use.)
Do you have any mercury amalgams? (If no, were they removed? If so, how?)
Have you had any root canals? (If yes, how many and when?)
Do you have any comers about your oral or dental health? (Gums bleed after flossing, receding gums)
Is there anything else about your current oral or dental health or health history that you’d like me to know?
Sleep history
Are you satisfied with your sleep?
Do you stay awake all day without dozing?
Are you asleep (or trying to sleep) between 2:00am and 4:00am?
Do you fall asleep in less than 30 minutes?
Do you sleep between 6 and 8 hours per night?
Is there anything else you would like me to know about your sleep?
Reproductive Hormone History
If you do not have female reproductive organs please skip below to the next section, Mental Health Status
How old were you when you first got your period?
How are/were your menses? Do/did you have PMS? Painful periods? If so, explain.
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you/do you still take birth control pills: If so, please list length of time and type.
Have you had any problems with conception pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.
Mental Health Status
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
On a scale of 0-10, one being the worst and 10 being the best, describe your usual level of energy.
At what point in your life did you feel best? Why?
Other
Do you think your family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in your family or in your health care team will be most supportive of you making dietary changes?
What role does spirituality play in your life?
Please describe any other information you think would be useful in helping to address your health concern(s):
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Should be Empty: