IHS - Patient Health Update

IHS Patient Health Update

Let us know what's going on with you!
Date of Update *

Month Day Year
Full Name *

First Name Middle Name Last Name
Prefferred Name
Email
example@example.com
Are you consistently taking your recommended supplement protocol? *

Yes No
How are you tolerating the recommended supplemental / dietary recommendations? *
What product(s) are you taking outside of your recommended protocol (Rx, vitamins, supplements...etc...) *
Do you need refills on recommended products?
Refills needed
Keto-Korner:

If Dr. Debbie has recommended you go on a Ketogenic Diet, please provide the following information
Birthday

Month Day Year
Birth Date
Current Height
Current Weight
Are You:

Sedentary. Lightly active. Moderately active. Very active.
Please describe your activity level:
Activity Level Description
On average, how many Carbs are you consuming each day?
Carbs in grams
Provide a description of your typical breakfast:
include overall ingredients if making a shake/smoothie or something similar
Provide a description of your typical lunch:
include overall ingredients if making a shake/smoothie or something similar
Provide a description of your typical dinner:
include overall ingredients if making a shake/smoothie or something similar
Provide a description of your typical snacks:
include overall ingredients if making a shake/smoothie or something similar
How much water are you drinking a day
water consumption in ounces
Update Questions:

Please answer the below questions to the best of your ability
How would you rate your quality of sleep?

Same Better Worse I do not have issues with sleep
I'm having difficulty sleeping because of: (select all that apply)

Mind Racing Heart Palpitations Jet Lag Caffeine Consumption Stress Getting up to Pee Pain
Please provide details:
Sleep Issues
Do you experience headaches?

Yes No On Occasion I do not have issues with headaches
If yes, where are your headaches located?
Location of Headaches
Do you experience pain?

Yes No Sometimes I do not have issues with pain
If yes, has your pain decreased at all?

Yes No
Please provide details:
Location of Pain
Has your mood improved?

Yes No On Occasion I do not have issues with my mood :)
Please provide details:
Mood
Has your energy level increased?

Yes No On Occasion I do not have issues with my energy levels :)
Please provide details:
Energy
How many bowel movements do you have each day?
# of BM
If not daily, how often?
Frequency of BM

Do you experience any of the following?

	Indigestion	Bloating	Gas	Belching	Reflux	Other	N/A
Select all that apply

Please describe "Other":
Since your last bio-feedback scan, have you received any new diagnoses? *

Yes No
If Yes, please describe:
Recent Diagnoses
Is there anything specific you would like Dr. Debbie to address while she runs your bio-feedback scan? Please describe: (if not, she will do a comparison based on your last bio-feedback scan) *
Specific Item(s) to address on bio-feedback scan
Additional notes for Dr. Debbie:
Additional Notes
IHS MSQ UPDATE (Medical Symptoms Questionnaire)

Select each of the following symptoms based on your typical health profile for the last two weeks
Select ALL that apply based on your typical health profile for the last 2 weeks.

Headaches Faintness Dizziness Insomnia Watery/ Itchy Eyes Swollen/ Red/Sticky Eyelids Bags/ Dark Circles under Eyes Blurred/ Tunnel Vision Itchy Ears Earaches/ Ear Infections Drainage in Ears Ringing/ Hearing Loss Stuffy Nose Sinus Issues Hay Fever Sneezing Attacks Excessive Mucus Chronic Coughing Gagging/ Frequent need to Clear Throat Sore Throat/ Hoarseness/ Loss of Voice Swollen/Discolored Tongue, Gums, or Lips Canker Sores Acne Hives/ Rashes/ Dry Skin Hair Loss Flushing/ Hot Flashes Excessive Sweating Irregular/ Skipped Heartbeat Rapid/ Pounding Heart Chest Pain Chest Congestion Asthma/ Bronchitis Shortness of Breath Difficulty Breathing Nausea/ Vomiting Diarrhea Constipation Bloating Belching/ Passing Gas Heartburn Reflux Intestinal/ Stomach Pain Pain/Aches in Joints Arthritis Stiffness/ Limitation of Movement Pain/Aches in Muscles Feeling of Weakness/ Tiredness Binge Eating/ Drinking Craving Certain Foods Excessive Weight Compulsive Eating Water Retention Underweight Fatigue/ Sluggishness Apathy/ Lethargy Hyperactivity Restlessness Poor Memory Confusion/ Poor Comprehension Poor Concentration Poor Physical Coordination Difficulty Making Decisions Stuttering/ Stammering Slurred Speech Learning Disabilities Mood Swings Anxiety/ Fear/ Nervousness Anger/ Irritability/ Agressiveness Depression Frequent Illness Frequent/ Urgent Urination Genital Itch/ Discharge
Additional Notes:
Any other information you would like to add
Should be Empty:

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IHS Patient Health Update

Keto-Korner:

Update Questions:

IHS MSQ UPDATE (Medical Symptoms Questionnaire)