Alternative Medicine Questionnaire

LawsOnHealth Wellness, LLC

Dr. Lesa Lawson, ND, CHHC, AADP
Health History Questionnaire

Confidential
Date of your Appointment

Month Day Year Date Picker Icon
Full Name *

First Name Last Name
Sex *

Female Male

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
E-mail
Skype Screen Name
Referred By:
Date of Birth *

Month Day Year
Age *
Height *
Weight
Eye Color
Blood Type
Family Physician
Physician's Phone Number

Area Code Phone Number
Vitals
Blood Pressure

Left Side Right Side
Pulse
Basal Temperature
pH Level

Urine Saliva
End - Vitals
Lifestyle/General Habits
How many bowel movements do you have, per day? *
How much water do you drink, daily?
Do you smoke/vape, drink alcohol, or chew tobacco?
Do you use recreational drugs?
Do you drink beverages/water with meals?
What is your source of drinking water?
Do you use a microwave?
Of what does your diet consist (What do you eat)?
Note

Note: Some questions may be repeated, as they apply to different body systems.
Thyroid/Parathyroid (Glandular System)
Do you get cold hands and feet?

Yes No
Is it easy to put on weight and hard to lose it?

Yes No Maybe
Are your fingernails ridged, brittle or weak?

Ridged Brittle Weak None of the above
Do you have varicose or spider veins?

Yes No
Do you, or have you had hemorrhoids or prolapsed organs?

Hemorrhoids Prolapsed organs No
Do you get cramping in your muscles?

Yes No
Is your bladder strong or weak?

Strong Weak
Do you have Mitral Valve Prolapse (Heart Murmur)?

Yes No
Do you have headaches or migraines?

Yes No
Have you ever had a hernia?

Yes No
Have you ever had an aneurysm?

Yes No
Do you have osteoporosis?

Yes No
Do you have scoliosis?

Yes No
Do you get irritable, easily?

Yes No
Do you have low energy levels?

Yes No
Do you suffer from symptoms of depression?

Yes No
Did you score low on your bone density tests?

Yes No N/A
Do your tests show low calcium levels?

Yes No
Do you have, or have you ever had, a goiter?

Yes No
Do you have spine deterioration, herniated discs, or bone spurs?

Yes No
Have you been diagnosed with Hashimoto's or Riedel's disease?

Yes No Family member
How much do you sweat?

A lot Somewhat Not at all
Do your legs get tired or cramp after you walk?

Yes No
Do you bruise easily? (Parathyroid)

Yes No
End - Thyroid/Parathyroid (Glandular System)
Pancreas
Do you get gassy after eating?

Yes No
Do you feel that your foods just sit in your stomach?

Yes No
Do you have Acid Reflux?

Yes No
Do you see undigested food in your stools?

Yes No
Are you thin and have a hard time putting on weight?

Yes No
Does your food pass right through you (diarrhea)?

Yes No
Do you have moles on your body? (Adrenal and Pancreatic weakness)

Yes No
End - Pancreas
Adrenal Glands
Medulla (Adrenal)
Are you overweight?

Yes No
Do you have Multiple Sclerosis, Parkinson's or Palsy?

Yes M.S. Parkinson's Palsy No
Do you have anxiety attacks, or feel overly anxious?

Yes No
Do you feel excessive shyness or inferiority toward others?

Yes No
Do you have tremors, nervous legs, etc.?

Yes No
Do you have high or low blood pressure?

High Low Average/Regular
What is your blood pressure? eg. 120/60
Do you have hypoglycemia (low blood sugar)?

Yes No
Do you have Diabetes (high blood sugar)?

Pre-Diabetes Type I Type II No
Do you have Tinnitus (ringing in the ears)?

Yes No
Do you have shortness of breath or is it hard to take a deep breath?

Yes No
Do you have insomnia, i.e, difficulty falling and/or staying asleep (Pineal)

Yes No
Do you have Chronic Fatigue Syndrome?

Yes No
Have you ever been diagnosed with Addison's Disease or Congenital Adrenal Hyperplasia?

Yes Addison's Congenital Adrenal Hyperplasia No
Cortex (Adrenal)
Do you have elevated blood cholesterol levels?

Yes No
Do you have arthritis, bursitis, cystitis or any other inflammatory issues?

Yes No
Explain
Do you have low cortisol levels?

Yes No
End - Adrenal Glands
Females Only
Is your menstruation irregular? (Pituitary)

Yes No I am menopausal I am not yet menstruating
Do you have excessive bleeding during menstruation?

Yes No
Do you have or have you had ovarian cysts?

Yes No
Do you have or have you had fibroids?

Yes No
Do you have or have you had endometriosis or A-typical cells?

Yes No
Do you have or have you had fibrocystic breasts?

Yes No
Do you get sore breasts, especially during menstruation?

Yes No
Do you have a low or high sex drive?

Low High Average
Have you had a hysterectomy?

Yes No
If yes, when? State if partial or full
Was any other organ removed at that same time? (ex: gallbladder)

Yes No
If yes, what other organ(s)?
Have you ever had a D & C?

Yes No
Have you had a miscarriage?

Yes No
Have you had a difficulty conceiving children?

Yes No
Have you been on birth control pills?

Yes No
If yes, for how long?
Are you currently pregnant?

Yes No
Hormone Imbalance (Check all that apply)

Hot flashes Heart palpitations PMS Mood swings Foggy thinking Urinary incontinence Vaginal dryness Increased body/facial hair Night sweats History of steroid usage Morning or Evening Fatigue Allergies Food Cravings Susceptible to Infections
Are you taking/using hormone treatments?

Yes No
If so, please list them
End of 'Females-Only' Section
Males Only
Do you have prostatitis (frequent urination, especially at night)?

Yes No
If yes, how often do you urinate?
Do you have prostate cancer?

Yes No
If yes, What are your PSA counts?: Test Date:
Do you have testicular hypertrophy (enlargement)?

Yes No
Do you have a low or excessive sex drive?

Low Excessive Average
Do you have premature ejaculation?

Yes No
Hormone Imbalance (Check all that apply)

Night sweats Hot flashes Irritable Foggy thinking Infertility Fatigue Dry Skin Feeling cold Headaches Heart palpitations Fibromyalgia Stress lots of infections Lack of motivation Weight gain (waist) Burned-out feeling Erectile dysfunction Decreased mental sharpness
End of 'Males-Only' Section
Gastro-Intestinal Tract
Do you have gastritis, enteritis or gastroparesis?

Yes No
Is your tongue coated (white, yellow, green, or brown), especially in the morning?

Yes No
Do you have a hiatal hernia?

Yes No
Do you have colitis?

Yes No
Do you have diverticulitis?

Yes No
Do you tend to have diarrhea?

Yes No
Do you tend to be constipated?

Yes No
Have you ever had stomach or intestinal ulcers?

Yes No
Have you had any type of gastro-intestinal cancer? (stomach, colon, rectal, etc.)

Yes No
If yes, explain:
Do you have Crohn's Disease?

Yes No
Do you tend to be gassy?

Yes No
Other gastrointestinal (GI) problems?
End - Gastro-Intestinal Tract
Liver/Gallbladder/Blood
Do you have a problem digesting fats?

Yes No
Do fats or dairy foods cause bloating and/or pain in the stomach area?

Yes No
Are your stools white or very light brown in color?

Yes No
Do you get pain behind the right, lower rib area?

Yes No
Do you have "liver" or brown spots on your skin? (not freckles)

Yes No
Are you jaundiced (yellowing of the skin)?

Yes No
Do you have skin pigmentation changes?

Yes No
Are you or have you ever been anemic?

Yes No
Do you have, or have you had, hepatitis?

Yes No
If yes, please indicate A, B, or C:
End - Liver/Gallbladder/Blood
Heart and Circulation
Do you have an irregular heartbeat (arrhythmia)?

Yes No
Do you get chest pains or angina?

Yes No
Have you ever had a heart attack (Myocardial Infarction)?

Yes No
Have you ever had open-heart surgery?

Yes No
If so, what kind?
Do you have a heart murmur or Mitral Valve Prolapse?

Yes No
Do you ever feel pressure on your chest?

Yes No
Do you get "prickly" pains anywhere, especially in the heart area?

Yes No
If so, Where?
Do you have, or have you ever had High Blood Pressure? (kidneys)

Yes No
Do you have a Pacemaker or Stints?

Yes Pacemaker Stints No
End - Heart and Circulation
Skin
Do you have skin rashes?

Yes No
Do you get skin blemishes?

Yes No
Do you have Eczema or Dermatitis?

Yes No
Do you have Psoriasis?

Yes No
Do you itch anywhere, continuously?

Yes No
If so, where?
Is your skin:

Dry Oily Combo
Do you have dandruff?

Yes No
Do you have other skin problems?

Yes No
If so, what type:
End - Skin
Lymphatic System
Do you have hair loss or are you bald or going bald?

Yes No
Have you ever had lymph nodes removed?

Yes No
Have you ever had a goiter?

Yes No
Do you have any gray hair?

Yes No
Do you have a hard time remembering things?

Yes No
Do you ever get colds or flu-like symptoms?

Yes No
Do you have fibromyalgia or scleroderma?

Yes No
Do you have sinus problems?

Yes No
Do you tend to get sore throats?

Yes No
Do you have swollen lymph nodes?

Yes No
Have you had tumors?

Yes No
If so, where?
Type

Fatty Benign Malignant
Do you have a low platelet count (blood)?

Yes No
Is your immune system weak or sluggish?

Yes No
Have you had appendicitis or an appendectomy?

Yes No
When?
Do you get boils, pimples, cysts, etc.?

Yes No
Do you get regular exercise?

Yes No
How many times per week?
Have you ever had abscesses?

Yes No
Have you ever had toxemia?

Yes No
Do you have, or have you had, cellulitis?

Yes No
Have you ever had gout?

Yes No
Do you have blurred vision?

Yes No
Do you have mucus in your eyes, when you awaken in the morning?

Yes No
Do you snore?

Yes No
Do you have sleep apnea?

Yes No
Have your tonsils been removed?

Yes No
At what age?
End - Lymphatic System
Kidneys and Bladder
Have you ever had a urinary tract infection (UTI)?

Yes No
Have you had burning with urination?

Yes No
Do you have problems holding your bladder? (Parathyroid)

Yes No
Have you ever had kidney stones?

Yes No
Is your urine flow restricted?

Yes No
Do you get cramping or pain on either side of your mid-to-lower back?

Yes No
Do you have bags under your eyes, especially in the morning?

Yes No
Have you ever had nephritis?

Yes No
Do you have lower back weakness?

Yes No
Do you have or have you had sciatica?

Yes No
Do you or did you ever have cystitis?

Yes No
End - Kidneys and Bladder
Lungs
Do you get or have (or have had) any of the following?:

Bronchitis Emphysema Asthma C.O.P.D.
Are you using inhalers or nebulizers?

Yes No
How often?
What type?
Oxygen saturation level?
Do you have pain when you breathe?

Yes No
Is it difficult to take a deep breath? (Adrenals)

Yes No
Have you ever had lung cancer?

Yes No
Do you have a collapsed lung?

Yes No
Are you a smoker?

Yes No
If yes, of cigarettes or marijuana?
How many, per day?
Have you ever had pneumonia?

Yes No
Have you ever worked around toxic chemicals, in coal mines, or around asbestos?

Yes No
Do you cough a lot?

Yes No
Do you have mucus when you cough?

Yes No
What color is the mucus?

clear yellow green brown black
End - Lungs
Environmental Toxins
Have you been vaccinated?

Yes No
Have you had shots for traveling to foreign countries?

Yes No
Have you had flu shots?

Yes No
Do you have mercury amalgams (fillings)?

Yes No
Do you find it difficult to take deep breaths?

Yes No
Have you been exposed to any of the following:

nuclear wastes or by-products heavy metals chemicals
If yes to above, please elaborate:
Have you had radiation or chemotherapy?

No Radiation Chemotherapy
If so, how many treatments?
End - Environmental Toxins
Chemical Medications

List all medications you are currently taking
Medication Names and Reason for taking:
List all supplements that you are currently taking
Allergies (Food/Seasonal/Environmental):
Past Surgeries - major and minor, and the year
Genetic/Family Medical History
Mother (How is/was her health?)
Father (How is/was his health?)
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
Sister(s)
Brother(s)
You are nearing the end.
What are your major health concerns (please list anything that was not addressed in this questionnaire): *
Option to upload any document you feel is relevant
Option to attach eye photo (left)
Option to attach eye photo (right)
Thank you!
ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT - CONFIDENTIAL / HIPPA APPROVED FORM

NOTICE OF PRIVACY PRACTICES

The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us, and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

LawsOnHealth Wellness, LLC

I understand the Notice of Privacy Practices
INFORMED CONSENT I am solely responsible for the decision to see Lesa Lawson, ND for naturopathic services and health coaching. I recognize that some recommendations may not prove to be successful. I understand that some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concern to Dr. Lesa Lawson or her staff. I also understand that any significant symptom should be reported to my doctor. I further understand that I should discuss the use of nutritional supplements with my doctor. *
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LawsOnHealth Wellness, LLC

Health History Questionnaire

Vitals

Lifestyle/General Habits

Note

Thyroid/Parathyroid (Glandular System)

Pancreas

Adrenal Glands

Females Only

Males Only

Gastro-Intestinal Tract

Liver/Gallbladder/Blood

Heart and Circulation

Skin

Lymphatic System

Kidneys and Bladder

Lungs

Environmental Toxins

Chemical Medications

Genetic/Family Medical History

You are nearing the end.

Thank you!