Functional Health Inquiry Form
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Name
First Name
Last Name
Gender
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Male
Female
N/A
Date of Birth
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Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Email
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SYMPTOMS SCORE SCARD
Please take your time filling out each section. There are 6 sections to complete.
HORMONE
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
best sleep between 7-9 am
constipation
crave salt
crepey skin at neck and/or eyelids
delicate joints or cartilage
difficulty concentrating/ learning new things
diminished sex drive, low libido
do not wake feeling refreshed
drowsy during the day
energy dips in the afternoon
exercise exhausts, makes me feel worse
fatigue not relieved by sleep
female fertility issues
gets tearful easily
hair loss/ thinning hair
hard to calm down
headaches
heavy menstrual bleeding
impotence
incontinence
increased effort to perform daily tasks
increased or excessive facial or body hair
irritable/ short-tempered
lack of motivation
loss of bone density
loss of muscle mass/ inability to keep muscle
male fertility issues
menstrual irregularities
nails brittle, break easily
night sweats
obessive/ circular thinking
often awake between 2-3 a.m. (not because I’m hungry)
oily skin
overweight
seasonal depression (during darker, colder months)
sensitivity to light
slow to get going in a.m. and/or like to sleep late
tender breasts - women
tender or enlarged breat tissue - men
tooth fractures
type "A" personality
vaginal dryness
IMMUNE
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
aversion to particular foods
coughs or colds usually last for weeks
digestive issues
dry skin
environmentally sensitive, reactive
fatigue
feeling of grit or dirt in the eye
frequent ear infections
frequent sore throats
frequent upset stomach
frequent urinary tract infections
frequently swollen glands
gets coughs or cold easily
gum inflammation/ bleeding
hay fever - seasonal allergies
headaches/ migraines
issues with blood clotting
joint pain
joint stiffness
joint swelling
joints are easily injured
losing strands or clumps of scalp hair
noise sensitivity
patchy hair loss on scalp, face, or arms
poor circulation
rashes/ hives frequently
receding gums
red, sensitive skin
ringing in ears
sensitivities to foods
sick often
sinus problems
skin extremely sensitive to sun
skin less responsive to external stimuli
skin on fingers, toes, ears, nose turns white/ blue when exposed to cold
slow healing of cuts or wounds
smells or fragrances cause headaches
swelling in hands or feet
swollen lymph nodes in armpit or neck
tooth decay
trouble concentrating
trouble swallowing
DIGESTION
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
abdominal cramping and/or bloating
acid reflux
acne
alternating constipation/ diaherra
black or tarry stools
bloating after eating
brain fog
brittle/ bendable nails
bulky stools
burning sensation in stomach
chest pain
chronic dry cough
cloudy urine
concentration difficulties
constipation
declining lean muscle mass
excessive sweating
foul smelling stool
frequent heartburn
frequent hiccups
frequent sore throat
greasy stools
intestinal gas after eating
issues digesting cruciferious vegetables
lack of appetite
lightheadedness
morning hoarseness
nausea
pain between the shoulder blades
rarely feel full and satisfied
regurgitation of food
scaly skin
sensation of a lump in throat
sensitive skin
slow healing
stool floats
trouble swallowing
unable to gain weight
unable to lose weight
undigested food in stool
wet burps
worsening fatigue
DETOXIFICATION
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
acne
aggressive behavior
bad breath
belching
bloating
constipation
dark circles under eyes
dark or brown urine color
dehydration
difficulty concentrating
difficulty sweating
dry eyes and mouth
feel nausea after eating fatty food
foamy urine
frequent chills
frequent diarrhea
getting winded more easily
headaches/ migraines
high cholesterol
insomnia
intolerant of strong smells
issues with short-term memory
metallic taste in mouth
muscle twitches
nausea
often have nightmares
pain in right side of abdomen
pain in the legs or lower back
patches of hardening skin
rashes, hives often
strong body odor
sweat burns skin
swelling in hands or feet
swelling/ puffiness in face
swollen glands in neck or nodes in armpit
tendency to bruise easily
tendency toward depression
tingling in hands and feet
tired or sluggish
waking between 1 and 3 am
weight gain
yellowing of eyes or skin
ENERGY PRODUCTION
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
apathy or emotional numbness after eating
depression or sadness after eating
dizziness or lightheadness
dry skin
energy highs and lows frequently during the day
feel angry and irritable easily
feel anxious after eating
feel exhausted, sleepy, lethargic after eating
feel fearful after eating
feel full too quickly
feel like something was missing after eating
feel nervous energy but tired underneath
feel physically full but still hungry after eating
feel the need to snack between meals
frequent mood swings
frequent sugar cravings
gets weak or shaky between meals
hungry soon after eating
hyper, jittery, nervous, or shaky after eating
inability to think quickly or clearly after eating
irregular heart beat
mentally slow, sluggish or spacy after eating
moist/ oily skin
never feel full or satistfied
obsessive/ circular thinking
slow healing of cuts or wounds
overly strong appetite
tendency to feel drowsy and lethargic
tendency to get rashes
tendency towards anxiety
tendency towards depression
tends to gain weight in belly
tends to gain weight in hips and thighs
tends to have delicate joints or cartilage
trouble concentrating
very hard to gain weight
very hard to lose weight
wakes in the night from hunger
weak appetite
Energy Production Total
NERVOUS SYSTEM
Always
Frequent
Often
Seldom
Rare
Never
agressiveness
anxiousness/ anxiety
autoimmune disorders
blurred or double vision
bright light causes pain
can't sit still
decreased ability to sense of hunger/ low blood sugar
depressed mood for sustained periods
difficulty swallowing/ gags frequently
dizziness on standing
easily startled
energy highs and lows frequently during the day
excitability
frequently worry
gets tearful easily
impulsiveness
lack of coordination
lack of motivation
ringing in ears
sleeping too many hours
tingling in limbs
weakening of grip strength
wide blood sugar fluctuations
OXIDATIVE STRESS
Always 5
Frequent 4
Often 3
Seldom 2
Rare 1
Never 0
abdominal swelling
balance issues
blood clotting issues
chronic pain
confusion
decreasing bone density
difficulty finding the right words when speaking
difficulty handling complex tasks
difficulty problem-solving
dilated pupils
dizziness
excessive thrist
frequent urination
graying hair
headaches/ migraines
heaviness in one or more limbs
high cholesterol
hyperpigmentation of skin
increased blood pressure
increased nervousness/ anxiety
insomnia
joint pain
lightheadedness
loss of elasticity in skin
memory loss
muscle cramps
muscle pain
noise sensitivity
numbness or tingling in limbs
rapid aging
skin pallor
skin rashes/ hives
suseptibilty to infections
swelling in ankles and feet
tendency to bruise easily
thinning skin
unstable blood sugar
worsening eyesight
worsening fatigue
wound healing issues
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