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ALLERGIESMedication/Supplement/Food Reaction

COMPLAINTS/CONCERNS

Functional and Integrative Medicine of McCall

MEDICALASSESSMENT

Name: Date: DOB: Whatdoyouhopetoachieveinyourvisitwithus? Ifyouhadamagicwandandcoulderasethreeproblems,whatwouldtheybe?1. 2. 3. Whenwasthelasttimeyoufeltwell? Didsomethingtriggeryourchangeinhealth? Whatmakesyoufeelworse? Whatmakesyoufeelbetter? Pleaselistcurrentandongoingproblemsinorderofpriority:

Severity Success

DescribeProblem Mild

Moderate

Severe

PriorTreatment/Approach Excellent

Good

Fair

Example:PostNasalDrip X EliminationDiet X

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MEDICALHISTORY þ=PastConditionþ=OngoingCondition

DISEASES/DIAGNOSIS/CONDITIONSCheckappropriateboxandprovidedateofonset

☐☐IrritableBowelSyndrome ☐☐InflammatoryBowelDisease ☐☐Crohn’s ☐☐UlcerativeColitis ☐☐GastritisorPepticUlcerDisease ☐☐GERD(reflux) ☐☐CeliacDisease ☐☐Other

☐☐HeartAttack ☐☐OtherHeartDisease ☐☐Stroke ☐☐ElevatedCholesterol ☐☐Arrhythmia(irregularheartrate) ☐☐Hypertension(highbloodpressure) ☐☐RheumaticFever ☐☐MitralValveProlapse ☐☐Other

☐☐Type1Diabetes ☐☐Type2Diabetes ☐☐Hypoglycemia ☐☐MetabolicSyndrome (InsulinResistanceorPre-Diabetes)☐☐Hypothyroidism(lowthyroid) ☐☐Hyperthyroidism(overactivethyroid) ☐☐EndocrineProblems ☐☐PolycysticOvarianSyndrome(PCOS) ☐☐Infertility ☐☐WeightGain ☐☐WeightLoss ☐☐FrequentWeightFluctuations ☐☐Bulimia ☐☐Anorexia ☐☐BingeEatingDisorder ☐☐NightEatingSyndrome ☐☐EatingDisorder(non-specific) ☐☐Other

☐☐LungCancer ☐☐BreastCancer ☐☐ColonCancer ☐☐OvarianCancer ☐☐ProstateCancer ☐☐SkinCancer

☐☐Other

☐☐KidneyStones ☐☐Gout ☐☐InterstitialCystitis ☐☐FrequentUrinaryTractInfections ☐☐FrequentYeastInfections ☐☐ErectileDysfunction orSexualDysfunction ☐☐Other

☐☐Osteoarthritis ☐☐Fibromyalgia ☐☐ChronicPain ☐☐Other

☐☐ChronicFatigueSyndrome ☐☐AutoimmuneDisease ☐☐RheumatoidArthritis ☐☐LupusSLE ☐☐ImmuneDeficiencyDisease ☐☐Herpes-Genital ☐☐SevereInfectiousDisease ☐☐PoorImmuneFunction (frequentinfections)☐☐FoodAllergies ☐☐EnvironmentalAllergies ☐☐MultipleChemicalSensitivities ☐☐LatexAllergy ☐☐Other

☐☐Asthma ☐☐ChronicSinusitis ☐☐Bronchitis ☐☐Emphysema ☐☐Pneumonia ☐☐Tuberculosis ☐☐SleepApnea

☐☐Other

☐☐Eczema ☐☐Psoriasis ☐☐Acne ☐☐Melanoma

GASTROINTESTINAL

METABOLIC/ENDOCRINE

CANCER

CARDIOVASCULAR MUSCULOSKELETAL/PAIN

INFLAMMATORY/AUTOIMMUNE

RESPIRATORYDISEASES

SKINDISEASES

GENITALANDURINARYSYSTEMS

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MEDICALHISTORY(cont…)☐☐SkinCancer ☐☐Other þ=PastConditionþ=OngoingCondition

☐☐Autism ☐☐MildCongitiveImpairment ☐☐Depression ☐☐MemoryProblems ☐☐Anxiety ☐☐Parkinson’sDisease ☐☐BipolarDisorder ☐☐MultipleSclerosis ☐☐Schizophrenia ☐☐ALS ☐☐Headaches ☐☐Seizures ☐☐Migraines ☐☐OtherNeurologicalProblems ☐☐ADD/ADHD PREVENTATIVETESTSAND SURGERIESDATEOFLASTTEST CheckboxifyesandprovidedateCheckboxifyesandprovidedate ☐Appendectomy ☐FullPhysicalExam ☐Hysterectomy+/-Ovaries ☐BoneDensity ☐Gallbladder ☐Colonoscopy ☐Hernia ☐CardiacStressTest ☐Tonsillectomy ☐EBTHeartScan ☐DentalSurgery ☐EKG ☐JointReplacement ☐HemoccultTest-stooltestforblood ☐HeartSurgery-BypassValve ☐MRI ☐AngioplastyorStent ☐CTScan ☐Pacemaker ☐UpperEndoscopy ☐Other ☐UpperGISeries ☐None ☐Ultrasound INJURIES BLOODTYPECheckboxifyes ☐A ☐B ☐AB ☐O☐BackInjury ☐HeadInjury Rh: ☐+ ☐- ☐unknown☐NeckInjury ☐BrokenBones☐OtherHOSPITALIZATIONS ☐NoneDate Reason COMMENTS

NEUROLOGICAL/MOOD

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OBSTETRICHISTORY(Checkboxifyesandprovidenumberof)

☐Pregnancies ☐Caesarean ☐VaginalDeliveries ☐Miscarriage ☐Abortion ☐LivingChildren: ☐PostPartumDepression ☐Toxemia ☐GestationalDiabetes☐Babyover8pounds ☐BreastFeeding–Forhowlong?

MENSTRUALHISTORY

Ageatfirstperiod: MensesFrequency Length: Pain?☐Yes☐No Clotting?☐Yes☐NoHasyourperiodeverskipped? Forhowlong? Useofhormonalcontraceptionsuchas:☐BirthControlPills☐Patch☐NuvaRingHowlong? Doyouusecontraception?☐Yes☐NoType:☐Condom☐Diaphragm☐IUD☐PartnerVasectomy

WOMEN’SDISORDERS/HORMONALIMBALANCES

☐FibrocysticBreasts ☐Endometriosis ☐Fibroids ☐Infertility☐PainfulPeriods ☐HeavyPeriods ☐PMSLastMammogram: ☐BreastBiopsy/Date: LastPAPtest: ☐Normal☐AbnormalDateofLastBoneDensity: Results:☐High☐Low☐WithinNormalRangeAreyouinmenopause?☐Yes☐NoAgeatMenopause ☐HotFlashes☐MoodSwings☐Concentration/MemoryProblems☐VaginalDryness☐DecreasedLibido☐HeavyBleeding☐JointPains☐Headaches☐WeightGain☐LossofControlofUrine☐Palpitations☐Useofhormonereplacementtherapy.Howlong?

HaveyouhadaPSAdone?☐Yes☐NoPSALevel:☐0-2☐2-4☐4-10☐>10☐Prostateenlargement ☐Prostateinfection ☐Changeinlibido ☐Impotence☐Difficultyobtaininganerection ☐Difficultymaintaininganerection☐Nocturia(urinationatnight) Howmanytimesatnight? ☐Urgency/Hesitancy/ChangeinUrinaryStream ☐LossofControlofUrine

GYNECOLOGICHISTORY(WOMENONLY)

MEN’SHISTORY(MENONLY)

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ForeignTravel?☐Yes☐NoWhere? WildernessCamping?☐Yes☐NoWhere? Haveyoueverhadsevere:☐Gastroenteritis☐DiarrheaDoyoufeellikeyoudigestfoodwell?☐Yes☐NoDoyougetbloatedaftermeals?☐Yes☐No

☐Term☐PrematurePregnancyComplications: BirthComplications: ☐BreastFed Howlong? ☐BottleFedAgeatintroductionof: SolidFoods: Dairy: Wheat: Didyoueatalotofcandyorsugarasachild?☐Yes☐No

DENTALSURGERY☐SilverMercuryFillings HowMany? ☐GoldFillings ☐RootCanals ☐Implants ☐ToothPain ☐BleedingGums☐Gingivitis ☐ProblemswithChewingDoyouflossregularly?☐Yes☐No

GIHISTORY

BIRTHHISTORY

DENTALHISTORY

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CURRENTMEDICATIONS

Medication Dose FrequencyStartDateMo/Yr ReasonForUse

PREVIOUSMEDICATIONSLast10years

Medication Dose FrequencyStartDateMo/Yr ReasonForUse

Haveyourmedicationsorsupplementsevercausedyouunusualsideeffectsorproblems?☐Yes☐No Describe: HaveyouhadprolongedorregularuseofNSAIDS(Advil,Aleve,etc.),MotrinAspirin?☐Yes☐NoHaveyouhadprolongedorregularuseofTylenol?☐Yes☐NoHaveyouhadprolongedorregularuseofAcidBlockingDrugs?(Tagamet,Zantac,Prilosec,etc.)☐Yes☐NoFrequentantibiotics>3times/year?☐Yes☐NoLongtermantibiotics?☐Yes☐NoUseofsteroids(prednisone,nasalallergyinhalers)inthepast?☐Yes☐NoUseoforalcontraceptives?☐Yes☐No

MEDICATIONS

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Checkfamilymembersthatapply Mother

Father

Brother(s)

Sister(s)

Children

Maternal

Grandm

other

Maternal

Grandfather

Paternal

Grandm

other

Paternal

Grandfather

Aunts

Uncles

Other

Age(ifsillalive)

Ageatdeath(ifdeceased)

Cancers

ColonCaner

BreastorOvarianCancer

HeartDisease

Hypertension

Obesity

Diabetes

Stroke

InflammatoryArthritis(Rheumatoid,Psoriatic,AnkylosingSpondylitis)

InflammatoryBowelDisease

MultipleSclerosis

AutoImmuneDiseases(suchasLupus)

IrritableBowelSyndrome

CeliacDisease

Asthma

Eczema/Psoriasis

FoodAllergies,SensitivitiesorIntolerances

EnvironmentalSensitivities

Dementia

Parkinson’s

ALSorotherMotorNeuronDiseases

GeneticDisorders

SubstanceAbuse(suchasalcoholism)

PsychiatricDisorders

Depression

Schizophrenia

ADHD

Autism

BipolarDisease

Other

FAMILYHISTORY

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NUTRITIONHISTORYHaveyoueverhadanutritionconsultation?☐Yes☐NoHaveyoumadeanychangesinyoureatinghabitsbecauseofyourhealth?☐Yes☐NoDescribe: Doyoucurrentlyfollowaspecialdietornutritionalprogram?☐Yes☐NoCheckallthatapply☐LowFat ☐LowCarbohydrate ☐HighProtein ☐LowSodium ☐Diabetic ☐NoDairy ☐NoWheat☐GlutenRestricted ☐Vegetarian ☐Vegan ☐Ultrametabolism☐SpecificProgramforWeightLoss/MaintenanceType: ☐Other Howoftendoyouweighyourself?☐Daily☐Weekly☐Monthly☐Rarely☐NeverHaveyoueverhadyourmetabolism(restingmetabolicrate)checked?☐Yes☐NoIfyes,whatwasit? Doyouavoidanyparticularfoods?☐Yes☐NoIfyes,whatarethetypesandreasons? Ifyoucouldonlyeatafewfoodsaweek,whatwouldtheybe? Doyougroceryshop?☐Yes☐NoIfno,whodoestheshopping? Doyoureadfoodlabels?☐Yes☐No Doyoucook?☐Yes☐NoIfno,whodoesthecooking? Howmanymealsdoyoueatoutperweek?☐0-1☐1-3☐3-5☐>5mealsperweekCheckallthefactorsthatapplytoyourcurrentlifestyleandeatinghabits:☐FastEater ☐Significantotherorfamilymembershavespecialdietaryneedsor☐Erraticeatingpattern foodpreferences☐Eattoomuch ☐Lovetoeat☐Latenighteating ☐EatbecauseIhaveto☐Dislikehealthyfood ☐Haveanegativerelationshiptofood☐Timeconstraints ☐Strugglewitheatingissues☐Eatmorethan50%mealsawayfromhome ☐Emotionaleater(eatwhensad,lonely,depressed,bored)☐Travelfrequently ☐Eattoomuchunderstress ☐Non-availabilityofhealthyfoods ☐Eattoolittleunderstress☐Donotplanmealsormenus ☐Don’tcaretocook☐Relianceonconvenienceitems ☐Eatinginthemiddleofthenight☐Poorsnackchoices ☐Confusedaboutnutritionadvice☐Significantotherorfamilymembersdon’tlikehealthyfoodsThemostimportantthingIshouldchangeaboutmydiettoimprovemyhealthis:

SOCIALHISTORY

Height(feet/inches) CurrentWeight UsualWeightRange+/-5lbs DesiredWeightRange+/-lbs Highestadultweight Lowestadultweight WeightFluctuations(>10lbs.)☐Yes☐No BodyFat%

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SMOKING

Currentlysmoking?☐Yes☐NoHowmanyyears? Packsperday: Attemptstoquite: Previoussmoking?☐Yes☐NoHowmanyyears? Packsperday: 2ndHandsmokeexposure?☐Yes☐NoHowmanyyears? ALCOHOLINTAKE

Howmaydrinkscurrentlyperweek?1dink=5ounceswine,12ouncesbeer,1.5ouncesspirits☐None☐1-3☐4-6☐7-10☐>10If“None”,skiptoOtherSubstancesPreviousalcoholintake?☐Yes(☐Mild☐Moderate☐High)☐NoneHaveyoueverbeentoldyoushouldcutdownyouralcoholintake?☐Yes☐NoDoyougetannoyedwhenpeopleaskyouaboutyourdrinking?☐Yes☐NoDoyoueverfeelguiltyaboutyouralcoholconsumption?☐Yes☐NoDoyouevertakeaneye-opener?☐Yes☐NoDoyounoticeatolerancetoalcohol(canyou“hold”morethanothers)?☐Yes☐NoHaveyoueverbeenunabletorememberwhatyoudidduringadrinkingepisode?☐Yes☐NoDoyougetintoargumentsorphysicalfightswhenyouhavebeendrinking?☐Yes☐NoHaveyoueverbeenarrestedorhospitalizedbecauseofdrinking?☐Yes☐NoHaveyoueverthoughtaboutgettinghelptocontrolorstopyourdrinking?☐Yes☐NoOTHERSUBSTANCES

Caffeineintake:☐Yes☐NoType:☐Coffee☐TeaCups/day:☐1☐2-4☐>4adayCaffeinatedSodasorDietSodasIntake:☐Yes☐No 12-ouncecan/bottle/day☐1☐2-4☐>4aday Listfavoritetype:(diet,Coke,Pepsi,etc.): Areyoucurrentlyusinganyrecreationaldrugs?☐Yes☐NoType HaveyoueverusedIVorinhaledrecreationaldrugs?☐Yes☐NoEXERCISE

CurrentExerciseProgram:Activity(listtype,numberofsessions/week,anddurationofactivity)Activity Type Frequencyperweek DurationinMinutesStretching Cardio/Aerobics Strength SportsorLeisureActivities Other Rateyourlevelofmotivationforincludingexerciseinyourlife?☐Low☐Medium☐HighListproblemsthatlimitactivity: Doyoufeelunusuallyfatiguedafterexercise?☐Yes☐NoIfyes,pleasedescribe: Doyouusuallysweatwhenexercising?☐Yes☐No

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PSYCHOSOCIAL

Doyoufeelsignificantlylessvitalthanyoudidayearago?☐Yes☐NoAreyouhappy?☐Yes☐NoDoyoufeelyourlifehasmeaningandpurpose?☐Yes☐NoDoyoubelievestressispresentlyreducingthequalityofyourlife?☐Yes☐NoDoyouliketheworkyoudo?☐Yes☐NoHaveyoueverexperiencedmajorlossesinyourlife?☐Yes☐NoDoyouspendthemajorityofyourtimeandmoneytofulfillresponsibilitiesandobligations?☐Yes☐NoWouldyoudescribeyourexperienceasachildinyourfamilyashappyandsecure?☐Yes☐NoSTRESS/COPING

Haveyoueversoughtcounseling?☐Yes☐NoAreyoucurrentlyintherapy?☐Yes☐NoDescribe: Doyoufeelyouhaveanexcessiveamountofstressinyourlife?☐Yes☐NoDoyoufeelyoucaneasilyhandlethestressinyourlife?☐Yes☐NoDailyStressors:Rateonscaleof1-10,10beingthehigheststressor.Work Family Social Finances Health Other Doyoupracticemeditationorrelaxationtechnique?☐Yes☐NoHowoften? Checkallthatapply:☐Yoga☐Meditation☐Imagery☐Breathing☐TaiChi☐Prayer☐Other: Haveyoueverbeenabused,avictimofacrime,orexperiencedasignificanttrauma?☐Yes☐NoSLEEP/REST

Averagenumberofhoursyousleeppernight:☐>10☐8-10☐6-8☐<6Doyouhavetroublefallingasleep?☐Yes☐NoDoyoufeelresteduponawakening?☐Yes☐NoDoyouhaveproblemswithinsomnia?☐Yes☐NoDoyousnore?☐Yes☐NoDoyouusesleepingaids?☐Yes☐NoExplain: ROLES/RELATIONSHIP

Maritalstatus:☐Single☐Married☐Divorced☐Gay/Lesbian☐LongTermPartnership☐WidowListchildren:Child’sName Age Gender WhoislivinginHousehold?Number: Names: TheirEmployment/Occupation: Resourcesforemotionalsupport?Checkallthatapply:☐Spouse☐Family☐Friends☐Religious/Spiritual☐Pets☐Other: Areyousatisfiedwithyoursexlife?☐Yes☐No

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Howwellhavethingsbeengoingforyou? VeryWell Fine Poorly DoesNotApplyOverall Atschool Inyourjob Inyoursociallife Withclosefriends Withsex Withyourattitude Withyourboyfriend/girlfriend Withyourparents Withyourspouse Withyourchildren

Doyouhaveknownadversefoodreactionsorsensitivities?☐Yes☐NoIfyes,describesymptoms Doyouhaveanyfoodallergiesorsensitivities?☐Yes☐NoListall: Doyouhaveanadversereactiontocaffeine?☐Yes☐NoWhenyoudrinkcaffeinedoyoufeel:☐IrritableorWired☐Aches&PainsDoyouadverselyreactto:Checkallthatapply:☐MonosodiumGlutamate(MSG)☐Aspartame(Nutrasweet)☐Bananas☐Garlic☐Onion☐Cheese☐Citrusfoods☐Chocolate☐Alcohol☐RedWine☐Sulfitecontainingfoods(wine,driedfruit,saladbars)☐Preservatives(ex.sodiumbenzoate)☐Other: Whichofthesesignificantlyaffectyou?Checkallthatapply:☐CigaretteSmoke☐Perfumes/Colognes☐AutoExhaustFumes☐Other: Inyourworkorhomeenvironment,areyouexposedto:☐Chemicals☐ElectromagneticRadiation☐MoldHaveyoueverturnedyellow(jaundiced)?☐Yes☐NoHaveyoueverbeentoldyouhaveGilbert’ssyndromeoraliverdisorder?☐Yes☐NoExplain: Doyouhaveknownhistoryofsignificantexposuretoanyharmfulchemicalssuchasthefollowing:☐Herbicides☐Insecticides(frequentvisitsofexterminator)☐Pesticides☐OrganicSolvents☐HeavyMetals☐Other ChemicalName,Date,LengthofExposure Doyoudrycleanyourclothesfrequently?☐Yes☐NoDoyouorhaveyoulivedorworkedinadampormoldyenvironmentorhadothermoldexposures?☐Yes☐NoDoyouhaveanypetsorfarmanimals?☐Yes☐No

ENVIRONMENTAL&DETOXIFICATIONACTIONASSESSMENT

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Pleasecheckallcurrentsymptomsoccurringorpresentinthepast6months.GENERAL☐ColdHands&Feet☐ColdIntolerance☐LowBodyTemperature☐LowBloodPressure☐DaytimeSleepiness☐DifficultyFallingAsleep☐EarlyWaking☐Fatigue☐Fever☐Flushing☐HeatIntolerance☐NightWaking☐Nightmares☐NoDreamRecallHEAD,EYES&EARS☐Conjunctivitis☐DistortedSenseofSmell☐DistortedTaste☐EarFullness☐EarPain☐EarRinging/Buzzing☐LidMarginRedness☐EyeCrusting☐EyePain☐HearingLoss☐HearingProblems☐Headache☐Migraine☐SensitivitytoLoudNoises☐VisionProblems(otherthan

glasses/contacts)☐MacularDegeneration☐VitreousDetachment☐RetinalDetachmentMUSCULOSKELETAL☐BackMuscleSpasm☐CalfCramps☐ChestTightness☐FootCramps☐JointDeformity☐JointPain☐JointRedness☐JointStiffness☐MusclePain☐MuscleSpasms☐MuscleStiffness

MuscleTwitches: ☐AroundEyes ☐ArmsorLegs☐MuscleWeakness☐NeckMuscleSpasm☐Tendonitis☐TensionHeadache☐TMJProblemsMOOD/NERVES☐Agoraphobia☐Anxiety☐AuditoryHallucinations☐Black-out☐DepressionDifficulty: ☐Concentrating ☐WithBalance ☐WithThinking ☐WithJudgment ☐WithSpeech ☐WithMemory☐Dizziness(Spinning)☐Fainting☐Fearfulness☐Irritability☐Light-headedness☐Numbness☐OtherPhobias☐PanicAttacks☐Paranoia☐Seizures☐SuicidalThoughts☐Tingling☐Tremor/Trembling☐VisualHallucinationsEATING☐BingeEating☐Bulimia☐Can’tGainWeight☐Can’tLoseWeight☐Can’tMaintainHealthyWeight☐FrequentDieting☐PoorAppetite☐SaltCravings☐CarbohydrateCraving

(breads,pastas)☐SweetCravings(candy,cakes,etc.)

☐ChocolateCravings☐CaffeineDependentDIGESTION☐AnalSpasms☐BadTeeth☐BleedingGumsBloatingof: ☐LowerAbdomen ☐WholeAbdomen ☐Bloatingaftermeals☐BloodinStools☐Burping☐CankerSores☐ColdSores☐Constipation☐CrackingatCornerofLips☐Cramps☐Denturesw/PoorChewing☐Diarrhea☐AlternatingDiarrhea/Constipation☐DifficultySwallowing☐DryMouth☐ExcessFlatulence/Gas☐Fissures☐Foods“Repeat”(reflux)☐Gas☐Heartburn☐Indigestion☐Nausea☐UpperAbdominalPain☐VomitingIntoleranceto: ☐Lactose ☐AllDairyProducts ☐Wheat ☐Gluten ☐Corn ☐Eggs ☐FattyFoods ☐Yeast☐LiverDisease/Jaundice (Yelloweyesorskin)☐AbnormalLiverFunctionTests☐LowerAbdominalPain☐MucusinStools☐PeriodontalDisease☐SoreTongue☐StrongStoolOdor☐UndigestedFoodinStool

SYMPTOMREVIEW

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SKINPROBLEMS☐AcneonBack☐AcneonChest☐AcneonFace☐AcneonShoulders☐Athlete’sFoot☐BumpsonBackofUpperArms☐Cellulite☐DarkCirclesUnderEyes☐EarsGetRed☐EasyBruising☐LackofSweating☐Eczema☐Hives☐JockItch☐LacklusterSkin☐Molesw/Color/SizeChange☐OilySkin☐PaleSkin☐PatchyDullness☐Rash☐SensitivetoBites☐SensitivetoPoisonIvy/Oak☐Shingles☐SkinDarkening☐StrongBodyOdor☐HairLoss☐VitiligoITCHINGSKIN☐SkininGeneral☐Anus☐Arms☐EarCanals☐Eyes☐Feet☐Hands☐Legs☐Nipples☐Nose☐Penis☐RoofofMouth☐Scalp☐ThroatSKIN,DRYNESSOF☐Eyes☐Feet ☐Cracking ☐Peeling☐Hair ☐Unmanageable

☐Hands ☐Cracking ☐Peeling☐Mouth/Throat☐Scalp ☐Dandruff☐SkininGeneralLYMPHNODES☐Enlarged/neck☐Tender/neck☐OtherEnlarged/TenderNAILS☐Bitten☐Brittle☐Curvedup☐Frayed☐Fungus-Fingers☐Fungus-Toes☐Pitting☐RaggedCuticles☐Ridges☐SoftThickeningof: ☐FingerNails ☐ToeNails☐WhiteSpots/LinesRESPIRATORY☐BadBreath☐BadOdorinNose☐DryCough☐Hoarseness☐SoreThroat☐HayFever ☐Spring ☐Summer ☐Fall ☐ChangeofSeason☐NasalStuffiness☐NoseBleeds☐PostNasalDrip☐SinusFullness☐SinusInfection☐Snoring☐Wheezing☐WinterStuffinessCARDIOVASUCLAR☐Angina/ChestPain☐Breathlessness☐HeartMurmur☐IrregularPulse

☐Palpitations☐Phlebitis☐SwollenAnkles/Feet☐VaricoseVeinsURINARY☐BedWetting☐Hesitancy(troublegettingstarted)☐Infections☐KidneyDisease☐Leaking/Incontinence☐Pain/Burning☐ProstateInfection☐UrgencyMALEREPRODUCTIVE☐DischargefromPenis☐EjaculationProblem☐GenitalPain☐Impotence☐ProstateorUrinaryInfection☐LumpsinTesticles☐PoorLibido(SexDrive)FEMALEREPRODUCTIVE☐BreastCysts☐BreastLumps☐BreastTenderness☐OvarianCyst☐PoorLibido(SexDrive)☐VaginalDischarge☐VaginalOdor☐VaginalItch☐VaginalPainwithSexPremenstrual: ☐BloatingBreastTenderness ☐CarbohydrateCravings ☐ChocolateCravings ☐Constipation ☐DecreasedSleep

☐Diarrhea☐Fatigue☐IncreasedSleep☐Irritability

Menstrual: ☐Cramps ☐HeavyPeriods ☐IrregularPeriods ☐NoPeriods ☐ScantyPeriods ☐SpottingBetween

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Rateonascaleof:5(verywilling)to1(notwilling).Inordertoimproveyourhealth,howwillingareyouto: Significantlymodifyyourdiet:☐5☐4☐3☐2☐1 Takeseveralnutritionalsupplementseachday:☐5☐4☐3☐2☐1 Keeparecordofeverythingyoueateachday:☐5☐4☐3☐2☐1 Modifyyourlifestyle(e.g.,workdemands,sleephabits):☐5☐4☐3☐2☐1 Practicearelaxationtechnique:☐5☐4☐3☐2☐1 Engageinregularexercise:☐5☐4☐3☐2☐1 Haveperiodiclabteststoassessyourprogress:☐5☐4☐3☐2☐1Comments: Rateonasaleof:5(veryconfident)to1(notconfidentatall)Howconfidentareyouofyourabilitytoorganizeandfollowthroughontheabovehealthrelatedactivities?:☐5☐4☐3☐2☐1Ifyouarenotconfidentofyourability,whataspectsofyourselforlifeleadyoutoquestionyoucapacitytofullyengageintheaboveactivities? Rateonasaleof:5(verysupportive)to1(veryunsupportive)Atthepresenttime,howsupportivedoyouthinkthepeopleinyourhouseholdwillbetoyourimplementingtheabovechanges?☐5☐4☐3☐2☐1Rateonascaleof:5(veryfrequentcontact)to1(veryinfrequentcontact)Howmuchon-goingsupportandcontact(e.g.telephoneconsults,emailcorrespondence)fromourprofessionalstaffwouldbehelpfultoyouasyouimplementyourpersonalhealthprogram?☐5☐4☐3☐2☐1Comments:

READINESSASSESSMENT