When answering the following questions, be as complete as you feel is necessary to communicate your state of health. The following symbols may be used if appropriate: Y = a condition you have now; N = never had: P = a condition you have had in the past. An intensity of symptom rating of 0-10 is helpful to identify the seriousness of a condition and to follow the progression of its resolution. If this is a significant issue, give essay type answers with important details.
General:
Weight: current, 1 yr. ago, maximum weight, when was maximum weight, do you diet to lose or maintain weight?
Height: maximum and current height, have you lost height, have you had a bone density scan?
Energy Level: exhausted, easily fatigued, adequate, very energetic, hyper/anxious/nervous
Temperature preference of environment, inside/outdoors: hot, warm, moderate, cool, cold
Sensitivity: Are you generally very rugged and able to handle stress, or does are you hypersensitive, reacting strongly to stresses?
Sleep: Hours, rested, dreams, nightmares, interruptions, day/night schedule
Skin:
Rashes: Eczema, psoriasis, prickly heat, Hives, candida, jock itch, tinea versicolor (ringworm)
Lesions: Acne, boils, pustular lesions
Itching: body, perianal, genital, head, body
Color change: vitiligo (loss of pigmentation), liver spots
Lumps: deep or superficial, fibromas, lipomas, keratomas
Growths: moles, skin tags, warts, cherry angiomas, seborrheic keratosis, basal cell carcinoma, skin cancer, melanoma
Sun damage: history of bad burns, sun worship (excessive sun tanning or tanning booth exposure)
Sweat: deficient, excessive (hands, feet, axilla), night sweats
Head
Headache: stress related, migraine, tumor, sinus pressure, light sensitivity
Head injury: severity, history of concussion,
Eyes
Impaired vision, Double vision, floaters
Glasses, contacts, lens implant after cataract surgery
Eye pain from light or other, excessive tearing or dryness
Glaucoma, Cataracts
Ears
Impaired hearing: cause, excessive ear wax, history of infection or tubes, food allergy relationship
Ringing: exposure to noise, history of infection
Earache:
Dizziness: related to infection, blood sugar, headache, toxic exposure
Nose and Sinuses
Frequent colds, frequent antibiotics, cause, duration
Nose bleeds, severity, frequency, cause
Chronic nasal congestion, Post nasal drip, episodes of sinusitis
Hay fever, seasonal allergies due to airborn/environmental allergens
Mouth and Throat
Frequent sore throat: deficient immune system, environmental exposure
Sore tongue: chew, smoke, dentures, lichen planus, fungal, herpes, cancre sores
Gum problems (gingivitis, bad breath, periodontal disease)
Hoarseness: smoke, excessive voice use, frequent infections, nodules, tumors
Dental: cavities filled with (Mercury/Silver, composite, gold, crowns, mixed type), extractions, bridges, dentures, root canals
Neck
Swollen glands: or frequent sore throat, lymphoma
Thyroid: Goiter pain or swelling, operation or radiation ablation, thyroid replacement, iodine supplement
Chronic cough, clearing throat, hoarseness, loss of voice, laryngitis, Post Nasal Drip irritation
Muscles, Nerves, Vessels: neck pain, tension/stress headaches, wry neck (torticollis), spinal surgery, restricted carotid artery
Respiratory
Cough: irritated, productive, bloody sputum
Wheezing: noises in chest detected by stethoscope or by unaided ears
Asthma: drugs used, severity of episodes, frequency of episodes, triggers
Bronchitis: chronic, or history of acute episodes
Pneumonia: history of, severity, treatment, frequency
Pleurisy: current or history of
Emphysema: use of medication, oxygen, lung function test results
Difficulty/pain breathing
Shortness of breath at night lying down
Tuberculosis: active or history of
Cardiovascular
Heart disease: Congestive heart Failure; history of Heart Attack (MI); angiography, BBB (Bundle Branch Block)
Heart Rhythm conditions: Palpitations, fluttering, atrial fibrillation, V Tach (Ventricular Tachycardia), PVC (Premature Ventricular Contractions)
Angina (chest pain): exercise induced heart pain, or unstable angina — unpredictable chest pain at rest.
High blood pressure: blood pressure,
Elevated Metabolic risk factors: Cholesterol, Fibrinogen, Homocysteine, C Reactive Protein
Murmurs: type, confirmation by imaging,
Infection: Rheumatic fever, Scarlet Fever, Endocarditis
Edema: Swelling in ankles, water retention,
Surgeries: Valve replacement, AS defect repair, Stent, CABG (bypass graft)
Gastrointestinal
Trouble swallowing: diagnosis of esophageal stricture or spasm by endoscopy; thyroid swollen; deficiency of saliva
Reflux: heartburn after meals; awaken coughing or hoarse from aspirated vomitus; stimulus (food, stress); necessary to elevate upper body to prevent reflux for sleeping; treated with antacids
Thirst: excessive or deficient; number of ounces of water per day; note: recommended ounces of water consumption = weight in pounds divided by two
Appetite: excessive or deficient; number of meals/day.
Nausea: frequency, stimulus (pregnancy, smells, food, drink…)
Vomiting: stimulus (excessive food or drink, viral infection, motion, tumor…)
Stool: Formation: well formed; constipated (<1 stool per day or two); diarrhea (watery), unformed stool (pie); number of bowel movements per day; has frequency changed; Stool color: normal medium brown, or green, clay, yellow, black, tarry; undigested food; blood in stool;
Gas: belching or intestinal gas (excessive)
Liver disease: Hepatitis A/B/C; chemical injury; alcoholic history; fatty liver; fibrosis/cirrhosis; elevated liver enzymes (ALT over 22)
Gall Bladder: inflammation (cholecystitis), history of Gall Bladder attacks, stones visualized by US/CT/MRI, jaundice, nausea with fats, surgical removal, size and number of stones, pancreatitis, (GGT over 40)
Ulcer: “coffee ground vomitus”, black tarry stool, central pain under xiphoid, better or worse with food or fasting
Hemorrhoids: bleeding, itching, internal, external, scars/skin tags/piles
Urinary Tract
Infection: blood or pain on urination; frequency of infections; cause of infection
Frequency of night time urination
Inability to hold urine: bladder prolapse, age, prostate enlargement, after childbirth
Kidney stones: type (oxalic, calcium…), frequency of episodes, cause, water consumption
Female Reproductive
Menses: Age menses began? Average number of days bleeding? Length of cycle? Bleeding between periods? Are cycles regular? Painful menses? Excessive flow? Heavy clotting?
Intercourse: sexually active, sexual difficulties, pain during Intercourse.
Libido: great, moderate, little desire, ability to climax, lack of responsiveness or sensation
Birth control? What type? Failures? IUD? History of Birth Control Pills?
Number of pregnancies, Number of live births, Number of miscarriages, Number of abortions, C section.
Fertility: difficulty conceiving, cause known: male or female, fertility drugs, in vitro fertilization, fertility studies
Menopausal symptoms; hot flashes, emotional lability, night sweats
Breasts: Do you do self exam? Lumps? Pain (or tenderness)? Nipple discharge
Venereal disease: Herpes, AIDS, history of chlamydia, syphilis, gonorrhea, venereal warts
Sexual preference: Heterosexual/Bisexual/Homosexual
Male Reproductive
Hernia: past repair, current inguinal bulge, or scrotal mass
Testicular masses, pain, varicocele (scrotum vein engorgement/varicosity), sperm deficiency (number, motility, prostatic fluid)
Sexual activity: Frequency of intercourse, satisfaction, level of libido
Sexual difficulties: impotence, premature ejaculation, delayed ejaculation, Peyronnie’s disease (bent penis)
Prostate disease (elevated PSA, prostate cancer, Prostatic Hypertrophy, urine retention, slow urination)
Venereal disease: History of: syphilis, gonorrhea, chlamydia; herpes outbreaks; genital warts
Infection: discharge, sores (herpetic, folliculitis, syphilis…), UTI
Sexual preference: Heterosexual/Bisexual/Homosexual
Musculoskeletal
Joints: pain, stiffness, large joints (hips, knees, ankles, knees, elbows, wrists, jaw), small joints (fingers, toes)
Back pain, level, cause, radiation (e.g. sciatica)
Arthritis, joint nodes, deformity, x-ray indication of joint damage
Muscle spasms, cramps, weakness, incoordination, tremors
Peripheral Circulation
Vascular Deep leg pain: thrombophlebitis (history/tendency to deep vein clots in legs — DVT)
Cold hands/feet, Raynaud’s syndrome (white fingers or toes with cold exposure)
Varicose veins: hemorrhoids, leg varicose veins, cherry angimoas
Easy flushing, blushing, blotching flushes with stress or food
Edema: swelling of legs, hands
Neurologic
Loss of consciousness: fainting, seizures, narcolepsy, petit mal, grand mal
Muscle weakness, paralysis, loss of/reduced coordination, Parkinson’s
Altered sensation: numbness, tingling, formication (ant crawling sensation)
Attention: easy distractibility, impulsiveness, hyperactivity, ADD, ADHD
Memory: deterioration, forgetfulness of dates, numbers, addresses, faces, objects, tasks, studies, appointments, Alzheimer’s
Consciousness: internal voices, visual hallucinations, repetitive behaviors, OCD, schizophrenia
Emotional
Depression, boredom, hopelessness, apathy, emotional fatigue, negative outlook, pessimism
Mood Swings: easily moved between moods, tears, anger, depression, anxiety, fear, bipolar diagnosis, borderline diagnosis
Anxiety: nervousness, internal tension, panic attacks
Jealousy: past history of betrayal, infidelity (self or other), easy or strong jealousy
Anger: angry outbursts, tendency to criticize, rageaholic
Fear: paranoid, suspicious, distrusting, avoid relationships, avoid committed relationships, agoraphobic
Violations: badly hurt or betrayed in love, friendship, or business; molested, raped, victim of crime, war trauma, PTSD
Immune
Swollen lymph nodes, chronic (long term) or acute (during an infection)
Susceptibility to infection, poorly/slowly resolving infections
Autoimmune diseases: Hashimotos, Sjogren’s, MS, Rheumatoid Arthritis, psoriasis
Immune deficiency: CFIDS, AIDS, chronic viral infection (EBV, CMV, HTLV…)
Supplement, lymph node removal/biopsy
Organ Transplant: immuno suppressant drugs
Lymphocyte Subset Panel: High or low WBC’s, B cells, T cells, T Helper, T Suppressor, NK cells
Leukemia, Lymphoma, Multiple Myeloma
Chemotherapy for cancer treatment
Endocrine
Hypothyroid: Heat or cold Intolerance, excessive hair loss
Pancreas: Insulin/Diabetes: excessive thirst, hunger, and/or urination
Parathyroid: Frequent muscle cramps
Pituitary: prolactinoma, milk production by male, or inappropriate from female
Adrenals: fatigue, Addison’s, cortisone high doses or long term
Thymus: immune dysfunction, chronic infections, frequent infections
Kidneys: anemia, blood pressure high, electrolyte disturbance
Libido: excessive or deficient sexual appetite