Functional Medicine Health Survey

Condition and major symptoms*

Rows	Please write a diagnosis of the conditions you received (or major symptoms you experience)	When diagnosed (or started)
Diagnosis
Diagnosis
Diagnosis
Diagnosis
Diagnosis

Select what is applicable to you*

Rows	None	Once or Twice a Week	Everyday
Alcohol or wine
Fast food
Artificial sweeteners
Fried food
Candy, desserts, refined sugar
Margarine
Soda drinks
Milk products
Cigarettes
Refined flour
Chewing tobacco
Tap water
Electronic cigarette/pipes
Distilled water
Recreational drugs
Exercise

Genetic predisposition: Please list medical conditions within your family’s health history *

Current Medication/Supplements *

Rows	None	Daily	Weekly	Any thoughts?
Bloating, burping, or discomfort after meals
Feeling particularly full after eating
Indigestion after meals
Burning sensation 30–40 minutes after eating
Undigested food in stool
Food allergies or intolerances
Experience chronic stress

Rows	None	Daily	Weekly	Monthly
Burning sensation immediately after eating
GERD
Heartburn worse when lying down at night
Stomach ulcers
Vomiting or nausea
Consume more than one caffeinated or alcoholic drink

Rows	None	Daily	Weekly	Monthly
Abdominal pain or discomfort
Bloating
Abdominal distension
Diarrhea
Flatulence
Weakness
Fatigue
Vitamin B12 deficiency
Iron deficiency
Excess folate

Rows	None	Daily	Weekly	Monthly
Chronic fatigue
Brain fog
Digestion problems
Craving sweets or carbohydrates
Vaginal itching, discharge, or soreness
Pain during intercourse (females)
Skin disorders such as psoriasis or patches
Itching of the skin in the lower abdomen or bra line
Exposure to old carpet (older than 3 years) or moist environment

How often do you experience the following

Rows	Yes	No
Do you live in a house that was built before 1978?
Are you smoking or have you smoked before for longer than a few months?

Rows	Yes	No
Dark spots on surfaces
Musty, damp, or earthy smell
Dark tile grout
Living with current or previous water damage
Warping, bubbling, or cracking wall surfaces (No / Yes)

Rows	Yes	No
Type 2 diabetes or prediabetic
Loss of bone mass: osteopenia or osteoporosis

Rows	Yes	No
Neurological conditions, such as Alzheimer’s, dementia, Huntington’s, or Parkinson’s
Neurobehavioral and psychiatric diseases, such as autism, schizophrenia, or bipolar
Depression and mood disorders
Type 2 Diabetes
An autoimmune condition, such as Lupus, Rheumatoid Arthritis
Multiple sclerosis
Cancer diagnosis
Heart or kidney disease

Rows	Yes	Monthly
Obesity or significant weight gain
Loss of muscle mass
Decrease in bone mass

Rows	Yes	No
Had or have allergies
Had or have a stressful/abusive relationship
Tired all the time
Work or used to work night shifts
Consumed steroids (e.g. prednisone) for over a month
Symptoms reduced with prescription of steroids
Pain reduced with cortisol injection

Rows	Yes	No
Do you have a tendency to be negative?
Are you often worried and anxious?
Are you a perfectionist or behave in an obsessive-compulsive way?
Do you have winter or seasonal depression?
Do you tend to be shy or have social phobias?
Do you have eating disorders?
Do you feel overwhelmed?
Do you crave carbs or chocolate often?
Are you using artificial sweeteners often?
Do you have difficulty sleeping that is relieved by melatonin supplements?

Rows	Yes	No
Do you tend towards addicting behaviors (such as alcohol, video games, pornography, or gambling)?
Do you experience anxiety or depression?
Do you have low self-esteem?
Do you tend to avoid painful or stressful conversations?
Have you been suffering from chronic pain (over 3 months)?
Do you have Fibromyalgia?

Rows	Yes	No
Tendency of addicting behavior, such as drugs, alcohol, pornography, video games, binge eating, or gambling
Attention disorders
Do you eat small amounts of protein?
Are you taking supplements of 5-HTP or L-Tyrosine?
Are you taking supplements of magnolia bark (Magnolia officinalis) or licorice root (Glycyrrhiza glabra)?
Tendency to be deficient in vitamin D
Do you experience tremors of the arm or have Parkinson’s disease?
Do you have fibromyalgia and chronic fatigue syndrome?

Rows	None	Daily	Weekly	Monthly
Use household air fresheners, laundry detergents, or cleaning products
Headaches
Irritability or anger
Chronic joint or muscle pain
Depression or mood swings
Chronic inflammation
Chronic fatigue
An autoimmune condition
Difficulty concentrating or brain fog
Have old dental fillings or had them removed
Drink tap water
Live or work in an industrial environment
Work in construction
Eat fish or seafood
Use deodorants
Use pesticides or herbicides in your home, garden, or on pets
Cook with aluminum baking plates
How often are you near high-powered electrical wires or transformers
Use household air fresheners, laundry detergents, or cleaning products
How often are you in a place without proper ventilation or air filtration
How often were you exposed to chemicals in the past

Rows	None	Daily	Weekly	Monthly
Weak voice
Red or watery eyes
Wheezing or shortness of breath
Mood disorders such as depression or anger
Lightheadedness or dizziness
Sneezing or coughing
Coordination problems
Nasal congestion
Allergic reaction
Postnasal drip
Atopic dermatitis
Memory impairment or brain fog
Mood disorders
Chronic fatigue

Rows	None	Daily	Weekly	Monthly
Irritability or depression
Hair loss
Headaches
High blood pressure
Fatigue
Irregular heartbeat
Loss of appetite and weight loss
Impotence or loss of sexual function
Muscle weakness
Muscle spasms or cramps
Cracked or sore lips
Tendency to feel depressed
Difficulty sleeping
Lower calcium levels in the blood
Loss of appetite
Impaired immune function
Decline in mental abilities such as memory or concentration
Sensation of numbness, tingling, or pins and needles

Rows	None	Daily	Weekly	Monthly
Fatigue during the day
Chronic joint pain and inflammation
Headaches
Nerve pain or neuropathy
High blood pressure
Muscle fatigue
Takes time to recover from physical activity
Memory problems
Chronic infections
Fibromyalgia