On-Line Health Assessment

Major Complaints:
(Please explain, in your own words, your reasons for consulting us what your
major symptoms and difficulties are, and what kind of solutions you are looking for.)

Exercise

How often to do you exercise?	Never A couple of times a month Once or twice a week Three or four times a week More than four times a week
How long a period do you exercise?	0-20 minutes 21-45 minutes Over 45 minutes
What type of exercise do you do?	Aerobic/cardiovascular Weight Training Yoga Other

Diet

Is your usual diet (check all that apply)

Standard American Avoid Red Meat Vegetarian Lacto-ovo

Vegan Lacto Vegetarian Avoid Wheat Avoid Processed Foods

Avoid Dairy Microwave Cook Canned Food Fats, Oils and Sweets

On average, how many servings a day do you have of the following? Bread, Pasta, Rice, Cereal (fiber) 1-5 6-11 Vegetables 1-3 3-5 Fruit 1-3 2-4 Meat, Poultry, Fish, Dry Beans, Eggs & Nuts 1-2 3 or more Dairy, (milk, cheese, eggs) 1-2 3 or more Water (8oz. glasses)

Medications

Prescriptive Medications You Currently Take: When listing prescriptive medications you currently take please indicate: name of drug, when started, dosage, reason for taking, and negative effects (if any). This will help in evaluating your responses to this questionnaire. Over-the-Counter Medications You Take Regularly: When listing over-the-counter medications you regularly take please indicate: name of drug, how often, and reason for using. This will help in evaluating your responses to this questionnaire. Nutritional Supplements and Herbs You Currently Take: When listing nutritional supplements and herbs you currently take please indicate: product name, manufacturer, dosage, reason for taking, recommended by, and if you feel it is helping, not helping, or can't determine. This will help in evaluating your responses to this questionnaire.

Medical History

Do you use tobacco?	Yes No Never
What alcoholic beverages do you drink?	None Beer Wine Spirits
How much and how often?	Occasionally A couple of drinks a week Once a day Have a problem controlling my habit  (more than 3 drinks a day)
Does any of your immediate family have a history of:	Anemia Angina Pectoris Bruise easily Breast Cancer Colon Cancer Chronic Fatigue Diabetes Difficulty Breathing/Shortness Heart Disease High Blood Pressure Hyperthyroid (Graves Disease) Hypothyroid (low) Obesity Osteoporosis Poor circulation Prostate Cancer Other Cancer Stroke TIA's
Do You presently have any of the following?	Anemia Angina Pectoris Bruise easily Breast Cancer Colon Cancer Chronic Fatigue Diabetes Difficulty Breathing/Shortness Heart Disease High Blood Pressure Hyperthyroid (Graves Disease) Hypothyroid (low) Obesity Osteoporosis Poor circulation Prostate Cancer Other Cancer Stroke TIA's
Cardiovascular and Circulatory Do you have any of the following Cardiovascular and Circulatory ailments?	Heart Attack High Blood Pressure Stroke TIA's Poor Circulation
Liver Do you have any of the following liver-related ailments?	Hepatitis A, B Hepatitis C, D, E Headaches Depression Melancholy Extreme General Fatigue Sluggish System, Constipation Unexplained Dizziness, Nausea, Shaking Food & Chemical Sensitivity Dry Tongue and Mouth Jaundiced Skin and/or liver spots PMS
Arthritis Have you been diagnosed with arthritis?	No Osteoarthritis Rheumatoid
If diagnosed with rheumatoid arthritis what is the RA factor?	Normal Abnormal
Does X-ray show bone deterioration?	Yes No
Does X-ray show cartilage deterioration?	Yes No
Which joints hurt?	Neck Shoulder Back Hips Knees Hands Feet/Ankles
Skin/Nails
Have Now: Eczema Dermatitis Fungal infections Skin infections Rashes Itching skin Dry skin Scaling skin Loss of Hair Nails break, split, or peel	Had in Past: Eczema Dermatitis Fungal infections Skin infections Rashes Itching skin Dry skin Scaling skin Loss of Hair Nails break, split, or peel
Allergies Do you have allergies?	None Family history of Allergies Airborne Food
Is allergic condition:	Chronic Acute Seasonal
Surgeries & Hospitalizations Are you undergoing any surgery within the next month?	Yes No
Have you had any surgery within the last 3 months?	Yes No
History of surgeries or hospitalizations: Please indicate the surgical procedure, your age at the time of surgery and the reason for the surgery. History of accidents and injuries Please indicate the accident that occurred, your age at the time of the accident, and how you were treated.
Stress/Tension
What do you feel is the level of stress in your life?	Low Average High Excessive
How do you handle stress and tension?	Unable to moderate Exercise Relaxation techniques, i.e. (meditation, deep breathing) Seek outside help
What is your overall state of mind?	Very happy, fulfilled Usually contented Sometimes unhappy, anxious Often anxious and depressed

For Women

Are you menopausal?	Yes No
When was your last Pap smear?	Months ago
When was your last mammogram?	Months ago
How often do you do your self breast exam?	Every month Twice a year Once a year Other
Any family history of breast cancer?	Yes No

For Men

When was your last prostate exam?	Months ago
What was the diagnosis?	Negative Benign Enlarged/hypertrophy Cancer
How often do you urinate at night?	Once Twice Three or more
Have you had a PSA test?	Yes No
What was the reading?	4 or less micrograms More than 4 micrograms # if known
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