IHS - Patient Health Update

IHS Patient Health Update

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

MonthDayYear
Full Name*

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

YesNo
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

MonthDayYear
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?

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

Mind RacingHeart PalpitationsJet LagCaffeine ConsumptionStressGetting up to PeePain
Please provide details:
Sleep Issues
Do you experience headaches?

YesNoOn OccasionI do not have issues with headaches
If yes, where are your headaches located?
Location of Headaches
Do you experience pain?

YesNoSometimesI do not have issues with pain
If yes, has your pain decreased at all?

YesNo
Please provide details:
Location of Pain
Has your mood improved?

YesNoOn OccasionI do not have issues with my mood :)
Please provide details:
Mood
Has your energy level increased?

YesNoOn OccasionI 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?*

YesNo
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.

HeadachesFaintnessDizzinessInsomniaWatery/ Itchy EyesSwollen/ Red/Sticky EyelidsBags/ Dark Circles under EyesBlurred/ Tunnel VisionItchy EarsEaraches/ Ear InfectionsDrainage in EarsRinging/ Hearing LossStuffy NoseSinus IssuesHay FeverSneezing AttacksExcessive MucusChronic CoughingGagging/ Frequent need to Clear ThroatSore Throat/ Hoarseness/ Loss of VoiceSwollen/Discolored Tongue, Gums, or LipsCanker SoresAcneHives/ Rashes/ Dry SkinHair LossFlushing/ Hot FlashesExcessive SweatingIrregular/ Skipped HeartbeatRapid/ Pounding HeartChest PainChest CongestionAsthma/ BronchitisShortness of BreathDifficulty BreathingNausea/ VomitingDiarrheaConstipationBloatingBelching/ Passing GasHeartburnRefluxIntestinal/ Stomach PainPain/Aches in JointsArthritisStiffness/ Limitation of MovementPain/Aches in MusclesFeeling of Weakness/ TirednessBinge Eating/ DrinkingCraving Certain FoodsExcessive WeightCompulsive EatingWater RetentionUnderweightFatigue/ SluggishnessApathy/ LethargyHyperactivityRestlessnessPoor MemoryConfusion/ Poor ComprehensionPoor ConcentrationPoor Physical CoordinationDifficulty Making DecisionsStuttering/ StammeringSlurred SpeechLearning DisabilitiesMood SwingsAnxiety/ Fear/ NervousnessAnger/ Irritability/ AgressivenessDepressionFrequent IllnessFrequent/ Urgent UrinationGenital Itch/ DischargeOther
Additional Notes:
Any other information you would like to add
Should be Empty:

IHS Patient Health Update

Keto-Korner:

Update Questions:

IHS MSQ UPDATE (Medical Symptoms Questionnaire)