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.


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


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


Headache: stress related, migraine, tumor, sinus pressure, light sensitivity

Head injury: severity, history of concussion,


Impaired vision, Double vision, floaters

Glasses, contacts, lens implant after cataract surgery

Eye pain from light or other, excessive tearing or dryness

Glaucoma, Cataracts


Impaired hearing: cause, excessive ear wax, history of infection or tubes, food allergy relationship 

Ringing: exposure to noise, history of infection


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


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


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


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)


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


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


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


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


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


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