Male Intake Questionnaire - …southwestfunctionalmedicine.com/wp-content/uploads/2018/03/... · Male Intake Questionnaire ... o Chocolate o Alcohol o Red wine o Sul!te–containing

General Information

Name ____________________________________________ Age _____ Today’s Date ___________________

Date of Birth ________________________ Email _________________________________________________

Address __________________________________ City ___________________ State ____ Zip _________

Phone (Home) _____________________ (Cell) ______________________ (Work) _____________________

Genetic Background: oAfrican American oHispanic oMediterranean oAsian oNative American oCaucasian oNorthern European

oOther _________________________________________________________________

When, where and from whom did you last receive medical or health care? ________________________________

___________________________________________________________________________________________

Emergency Contact: _____________________________________ Relationship ________________________

Phone (Home) _____________________ (Cell) ______________________ (Work) _____________________

How did you hear about our practice?

oClinic website oIFM website oReferral from doctor oReferral from friend/family memberoSocial media oOther ___________________________________________________________________

Current Health Concerns

Please rank current and ongoing health concerns in order of priority

Male Intake Questionnaire

Describe Problem Severity

Prior Treatment/Approach Success

Example: Post Nasal Drip X Elimination Diet X

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© 2015 The Institute for Functional MedicineVersion 2

IFM n Male Intake Questionnaire 2© 2015 The Institute for Functional Medicine

Allergies

Name of Medication/Supplement/Food: Reaction:

1.

2.

3.

4.

5.

Activity Type # of Times Per Week Time/Duration (Minutes)

Cardio/Aerobic

Strength/Resistance

Flexibility/Stretching

Balance

Sports/Leisure (e.g., golf)

Other:

Lifestyle Review

Sleep

How many hours of sleep do you get each night on average? ___________________________________________

Do you have problems falling asleep? oYes oNo Staying asleep? oYes oNoDo you have problems with insomnia? oYes oNo Do you snore? oYes oNoDo you feel rested upon awakening? oYes oNoDo you use sleeping aids? oYes oNo

If yes, explain: ______________________________________________________________________________

Exercise

Current Exercise Program:

Do you feel motivated to exercise? oYes oA little oNo

Are there any problems that limit exercise? oYes oNoIf yes, explain: ______________________________________________________________________________

Do you feel unusually fatigued or sore after exercise? oYes oNoIf yes, explain: ______________________________________________________________________________


Nutrition

Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)

oVegetarian oVegan oAllergy oElimination oLow Fat oLow Carb oHigh ProteinoBlood Type oLow sodium oNo Dairy oNo Wheat oGluten FreeoOther: _________________________________________________________________________________

Do you have sensitivities to certain foods? oYes oNoIf yes, list food and symptoms: _________________________________________________________________

Do you have an aversion to certain foods? oYes oNoIf yes, explain: ______________________________________________________________________________

Do you adversely react to: (Check all that apply)

oMonosodium glutamate (MSG) oArtificial sweeteners oGarlic/onion oCheese oCitrus foodsoChocolate oAlcohol oRed wine oSulfite–containing foods (wine, dried fruit, salad bars)oPreservatives oFood colorings oOther food substances: ____________________________________

Are there any foods that you crave or binge on? oYes oNo If yes, what foods?___________________________________________________________________________

Do you eat 3 meals a day? oYes oNo If no, how many _______________________________________

Does skipping a meal greatly affect you? oYes oNo

How many meals do you eat out per week? o0–1 o1–3 o3–5 o>5 meals per week

Check the factors that apply to your current lifestyle and eating habits:

oFast eateroEat too muchoLate-night eatingoDislike healthy foodsoTime constraintsoTravel frequentlyoEat more than 50% of meals away from homeoHealthy foods not readily availableoPoor snack choicesoSignificant other or family members don’t like

healthy foods

oSignificant other or family members have special dietary needs

oLove to eatoEat because I have tooHave negative relationship to foodoStruggle with eating issuesoEmotional eater (eat when sad, lonely, bored, etc.)oEat too much under stressoEat too little under stressoDon’t care to cookoConfused about nutrition advice


Diet

Please record what you eat in a typical day:

Breakfast ___________________________________________________________________________________

Lunch _____________________________________________________________________________________

Dinner _____________________________________________________________________________________

Snacks _____________________________________________________________________________________

Fluids ______________________________________________________________________________________

How many servings do you eat in a typical week of these foods:

Fruits (not juice) _____ Vegetables (not including white potatoes) _____Legumes (beans, peas, etc) _____ Red meat _____ Fish _____Dairy/Alternatives _____ Nuts & Seeds _____ Fats & Oils _____Cans of soda (regular or diet) _____ Sweets (candy, cookies, cake, ice cream, etc.) _____

Do you drink caffeinated beverages? oYes oNo If yes, check amounts:

Coffee (cups per day) o1 o2-4 o>4 Tea (cups per day) o1 o2-4 o>4Caffeinated sodas—regular or diet (cans per day) o1 o2-4 o>4

Do you have adverse reactions to caffeine? oYes oNoIf yes, explain: ______________________________________________________________________________

When you drink caffeine do you feel: oIrritable or wired oAches or pains

Smoking

Do you smoke currently? oYes oNo Packs per day: ______ Number of years _____What type? oCigarettes oSmokeless oPipe oCigar oE-CigHave you attempted to quit? oYes oNo

If yes, using what methods: ____________________________________________________________________

If you smoked previously: Packs per day: _____ Number of years _____Are you regularly exposed to second-hand smoke? oYes oNo

Alcohol

How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)o1–3 o4–6 o7–10 o>10 oNone

Previous alcohol intake? oYes (oMild oModerate oHigh) oNone

Have you ever had a problem with alcohol? oYes oNoIf yes, when? _______________________________________________________________________________Explain the problem: ________________________________________________________________________

Have you ever thought about getting help to control or stop your drinking? oYes oNo

Other Substances

Are you currently using any recreational drugs? oYes oNoIf yes, type: ________________________________________________________________________________

Have you ever used IV or inhaled recreational drugs? oYes oNo


N/A Poorly Fine Very Well

Overall o 1 2 3 4 5 6 7 8 9 10

At school o 1 2 3 4 5 6 7 8 9 10

In your job o 1 2 3 4 5 6 7 8 9 10

In your social life o 1 2 3 4 5 6 7 8 9 10

With close friends o 1 2 3 4 5 6 7 8 9 10

With sex o 1 2 3 4 5 6 7 8 9 10

With your attitude o 1 2 3 4 5 6 7 8 9 10

With your boyfriend/girlfriend o 1 2 3 4 5 6 7 8 9 10

With your children o 1 2 3 4 5 6 7 8 9 10

With your parents o 1 2 3 4 5 6 7 8 9 10

With your spouse o 1 2 3 4 5 6 7 8 9 10

Stress

Do you feel you have an excessive amount of stress in your life? oYes oNo

Do you feel you can easily handle the stress in your life? oYes oNo

How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)Work ____ Family ____ Social ____ Finances ____ Health ____ Other ____

Do you use relaxation techniques? oYes oNoIf yes, how often? ___________________________________________________________________________

Which techniques do you use? (Check all that apply)

oMeditation oBreathing oTai Chi oYoga oPrayer oOther: ___________________________

Have you ever sought counseling? oYes oNo

Are you currently in therapy? oYes oNoIf yes, describe: _____________________________________________________________________________

Have you ever been abused, a victim of crime, or experienced a significant trauma? oYes oNo

What are your hobbies or leisure activities? _________________________________________________________

Relationships

Marital status: oSingle oMarried oDivorced oGay/Lesbian oLong-Term Partner oWidow/er

With whom do you live? (Include children, parents, relatives, friends, pets) ________________________________

___________________________________________________________________________________________

Current occupation: __________________________________________________________________________

Previous occupations:__________________________________________________________________________

Do you have resources for emotional support? oYes ooNo (Check all that apply)

oSpouse/Partner oFamily oFriends oReligious/Spiritual oPets oOther: _______________

Do you have a religious or spiritual practice? oYes oNo

If yes, what kind? ___________________________________________________________________________

How well have things been going for you? (Mark on scale of 1–10, or N/A if not applicable)


History

Patient’s Birth/Childhood History:

You were born: oTerm oPremature oDon’t know

Were there any pregnancy or birth complications? oYes oNoIf yes, explain: ______________________________________________________________________________

You were: oBreast-fed/How long? _______ oBottle-fed/Type of formula: ___________ oDon’t know

Age of introduction of: Solid food: ______ Wheat _______ Dairy _______

As a child, were there any foods that were avoided because they gave you symptoms? oYes oNoIf yes, what foods and what symptoms? (Example: milk—gas and diarrhea) _________________________________________________________________________________________

_________________________________________________________________________________________

Did you eat a lot of sugar or candy as a child? oYes oNo

Dental History:

Check if you have any of the following, and provide number if applicable:

oSilver mercury fillings ____ oGold fillings ____ oRoot canals ____ oImplants ____oCaps/Crowns ____ oTooth pain ____ oBleeding gums ____ oGingivitis _____oProblems with chewing ____ oOther dental concerns (explain): _____

Have you had any mercury fillings removed? oYes oNo If yes, when: ____________________________

How many fillings did you have as a kid? ______________

Do you brush regularly? oYes oNo Do you floss regularly? oYes oNo

Environmental/Detoxification History

Do any of these significantly affect you?

oCigarette smoke oPerfume/colognes oAuto exhaust fumes oOther: ______________________

In your work or home environment are you regularly exposed to: (Check all that apply)

oMold oWater leaks oRenovations oChemicals oElectromagnetic radiationoDamp environments oCarpets or rugs oOld paint oStagnant or stuffy air oSmokersoPesticides oHerbicides oHarsh chemicals (solvents, glues, gas, acids, etc) oCleaning chemicalsoHeavy metals (lead, mercury, etc.) oPaints oAirplane travel oOther ________________________

Have you had a significant exposure to any harmful chemicals? oYes oNoIf yes: Chemical name, length of exposure, date: ____________________________________________________

Do you have any pets or farm animals? oYes oNoIf yes, do they live: oInside oOutside oBoth inside and outside

Men’s History

(Check box if applicable)

oTesticular mass oTesticular pain oProstate enlargement oProstate infection oChange in sex drive oImpotence oPremature ejaculation oDifficulty obtaining an erectionoDifficulty maintaining an erection oLoss of control of urine oUrinary urgency/hesitancy/change in streamoVasectomy oNocturia (urination at night) # of times per night _______________oSexually transmitted diseases (describe) ________________________________________________________


Men’s History (cont.)

Screening/Procedures: (If applicable, provide date)

Last PSA test: _____________________ PSA Level: o0–2 o2–4 o4–10 o>10

Other tests/procedures (list type and dates) _________________________________________________________

___________________________________________________________________________________________

Family History:

Check family members that have/had any of the following

Age (if still alive)

Age at death (if deceased)

Cancer o o o o o o o o o o o o o

Heart disease o o o o o o o o o o o o o

Hypertension o o o o o o o o o o o o o

Obesity o o o o o o o o o o o o o

Diabetes o o o o o o o o o o o o o

Stroke o o o o o o o o o o o o o

Autoimmune disease o o o o o o o o o o o o o

Arthritis o o o o o o o o o o o o o

Kidney disease o o o o o o o o o o o o o

Thyroid problems o o o o o o o o o o o o o

Seizures/epilepsy o o o o o o o o o o o o o

Psychiatric disorders o o o o o o o o o o o o o

Anxiety o o o o o o o o o o o o o

Depression o o o o o o o o o o o o o

Asthma o o o o o o o o o o o o o

Allergies o o o o o o o o o o o o o

Eczema o o o o o o o o o o o o o

ADHD o o o o o o o o o o o o o

Autism o o o o o o o o o o o o o

Irritable Bowel Syndrome o o o o o o o o o o o o o

Dementia o o o o o o o o o o o o o

Substance abuse o o o o o o o o o o o o o

Genetic disorders o o o o o o o o o o o o o

Other: o o o o o o o o o o o o o

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Gastrointestinal Yes Past

Irritable bowel syndrome o oGERD (reflux) o oCrohn’s disease/ulcerative colitis o oPeptic ulcer disease o oCeliac disease o oGallstones o oOther: o o

Respiratory

Bronchitis o oAsthma o oEmphysema o oPneumonia o oSinusitis o oSleep apnea o oOther: o o

Urinary/Genital

Kidney stones o oGout o oInterstitial cystitis o oFrequent yeast infections o oFrequent urinary tract infections o oSexual dysfunction o oSexually transmitted diseases o oOther: o o

Endocrine/MetabolicDiabetes o oHypothyroidism (low thyroid) o oHyperthyroidism (overactive thyroid) o oInfertility o oMetabolic syndrome/insulin resistance o oEating disorder o oHypoglycemia o oOther: o o

Inflammatory/Immune

Rheumatoid arthritis o oChronic fatigue syndrome o oFood allergies o oEnvironmental allergies o oMultiple chemical sensitivities o oAutoimmune disease o oImmune deficiency o oMononucleosis o oHepatitis o oOther: o o

Musculoskeletal Yes Past

Fibromyalgia o oOsteoarthritis o oChronic pain o oOther: o o

Skin

Eczema o oPsoriasis o oAcne o oSkin cancer o oOther: o o

Cardiovascular

Angina o oHeart attack o oHeart failure o oHypertension (high blood pressure) o oStroke o oHigh blood fats (cholesterol, triglycerides) o oRheumatic fever o oArrythmia (irregular heart rate) o oMurmur o oMitral valve prolapse o oOther: o o

Neurologic/EmotionalEpilepsy/Seizures o oADD/ADHD o oHeadaches o oMigraines o oDepression o oAnxiety o oAutism o oMultiple sclerosis o oParkinson’s disease o oDementia o oOther: o o

Cancer

Lung o oBreast o oColon o oProstate o oSkin o oOther: o o

Medical History: Illnesses/Conditions

Check YES = a condition you currently have, Check PAST = a condition you’ve had in the past.


Diagnostic Studies Date Comments

Bone density

CT scan

Colonoscopy

Cardiac stress test

EKG

MRI

Upper endoscopy

Upper GI series

Chest X-ray

Other X-rays

Barium enema

Other:

Injuries

Broken bone(s)

Back injury

Neck injury

Head injury

Other:

Surgeries

Appendectomy

Dental

Gallbladder

Hernia

Tonsillectomy

Joint replacement

Heart surgery

Other:

Hospitalizations Date Reason

Medical History (cont.)


Symptom Review

Please check if these symptoms occur presently or have occurred in the last 6 months

General Mild Moderate Severe

Cold hands and feet o o oCold intolerance o o oDaytime sleepiness o o oDifficulty falling asleep o o oEarly waking o o oFatigue o o oFever o o oFlushing o o oHeat intolerance o o oNight waking o o oNightmares o o oCan’t remember dreams o o oLow body temperature o o o

Head, Eyes, and Ears

Conjunctivitis o o oDistorted sense of smell o o oDistorted taste o o oEar fullness o o oEar ringing/buzzing o o oEye crusting o o oEye pain o o oEyelid margin redness o o oHeadache o o oHearing loss o o oHearing problems o o oMigraine o o oSensitivity to loud noises o o oVision problems o o o

Musculoskeletal

Back muscle spasm o o oCalf cramps o o oChest tightness o o oFoot cramps o o oJoint deformity o o oJoint pain o o oJoint redness o o oJoint stiffness o o oMuscle pain o o oMuscle spasms o o oMuscle stiffness o o oMuscle twitches: o o o

Around eyes o o oArms or legs o o o

Muscle weakness o o o

Musculoskeletal (cont.) Mild Moderate Severe

Neck muscle spasm o o oTendonitis o o oTension headache o o oTMJ problems o o o

Mood/Nerves

Agoraphobia o o oAnxiety o o oAuditory hallucinations o o oBlackouts o o oDepression o o oDifficulty: o o o

Concentrating o o oWith balance o o oWith thinking o o oWith judgment o o oWith speech o o oWith memory o o o

Dizziness (spinning) o o oFainting o o oFearfulness o o oIrritability o o oLight-headedness o o oNumbness o o oOther phobias o o oPanic attacks o o oParanoia o o oSeizures o o oSuicidal thoughts o o oTingling o o oTremor/trembling o o oVisual hallucinations o o o

Cardiovascular

Angina/chest pain o o o

Breathlessness o o o

Heart attack o o o

Heart murmur o o o

High blood pressure o o o

Irregular pulse o o o

Mitral valve prolapse o o o

Palpitations o o o

Phlebitis o o o

Swollen ankles/feet o o o

Varicose veins o o o


Symptom Review (cont.)


Urinary Mild Moderate Severe

Bed wetting o o oHesitancy o o oInfection o o oKidney disease o o oKidney stone o o oLeaking/incontinence o o oPain/burning o o oProstate enlargement o o oProstate infection o o oUrgency o o o

Digestion

Anal spasms o o oBad teeth o o oBleeding gums o o oBloating of: o o o

Lower abdomen o o oWhole abdomen o o oBloating after meals o o o

Blood in stools o o oBurping o o oCanker sores o o oCold sores o o oConstipation o o oCracking at corner of lips o o oDentures w/poor chewing o o oDiarrhea o o oDifficulty swallowing o o oDry mouth o o oFarting o o oFissures o o oFoods "repeat" (reflux) o o oHeartburn o o oHemorrhoids o o oIntolerance to: o o o

Lactose o o oAll dairy products o o oGluten (wheat) o o oCorn o o oEggs o o oFatty foods o o oYeast o o o

Liver disease/jaundice o o o(yellow eyes or skin)

Digestion (cont.) Mild Moderate Severe

Lower abdominal pain

Mucus in stools

Nausea o o oPeriodontal disease o o oSore tongue o o oStrong stool odor o o oUndigested food in stools o o oUpper abdominal pain o o oVomiting o o o

Eating

Binge eating o o oBulimia o o oCan't gain weight o o oCan't lose weight o o oCarbohydrate craving o o oCarbohydrate intolerance o o oPoor appetite o o oSalt cravings o o oFrequent dieting o o oSweet cravings o o oCaffeine dependency o o o

Respiratory

Bad breath o o oBad odor in nose o o oCough – dry o o oCough – productive o o oHayfever: o o o

Spring o o oSummer o o oFall o o oChange of season o o o

Hoarseness o o oNasal stuffiness o o oNose bleeds o o oPost nasal drip o o oSinus fullness o o oSinus infection o o oSnoring o o oSore throat o o oWheezing o o o


Symptom Review (cont.)


Nails Mild Moderate Severe

Bitten o o oBrittle o o oCurve up o o oFrayed o o oFungus – fingers o o oFungus – toes o o oPitting o o oRagged cuticles o o oRidges o o oSoft o o oThickening of: o o o

Finger nails o o oToenails o o o

White spots/lines o o o

Lymph Nodes

Enlarged/neck o o oTender/neck o o oOther enlarged/tender o o o

lymph nodes

Skin, Dryness of

Eyes o o o

Feet o o o

Any cracking? o o o

Any peeling? o o o

Hair o o o

And unmanageable? o o o

Hands o o o

Any cracking? o o o

Any peeling? o o o

Mouth/throat o o o

Scalp o o o

Any dandruff? o o o

Skin in general o o o

Skin Problems

Acne on back o o oAcne on chest o o oAcne on face o o oAcne on shoulders o o oAthlete’s foot o o oBumps on back of upper arms o o oCellulite o o oDark circles under eyes o o oEars get red o o o

Skin Problems (cont.) Mild Moderate Severe

Easy bruising o o oEczema o o oHerpes – genital o o oHives o o oJock itch o o oLackluster skin o o oMoles w color/size change o o oOily skin o o oPale skin o o oPatchy dullness o o oPsoriasis o o oRash o o oRed face o o oSensitive to bites o o oSensitive to poison ivy/oak o o oShingles o o oSkin cancer o o oSkin darkening o o oStrong body odor o o oThick calluses o o oVitiligo o o o

Itching Skin

Anus o o oArms o o oEar canals o o oEyes o o oFeet o o oHands o o oLegs o o oNipples o o oNose o o oGenitals o o oRoof of mouth o o oScalp o o oSkin in general o o oThroat o o o

Male Reproductive

Discharge from penis o o oEjaculation problem o o oGenital pain o o oImpotence o o oInfection o o oLumps in testicles o o oPoor libido (low sex drive) o o o


Medications/Supplements

Current medications (include prescription and over-the-counter)

Medication Dosage Start Date (mo/yr) Reason for Use

Nutritional supplements (vitamins/minerals/herbs etc.)

Name and Brand Dosage Start Date (mo/yr) Reason for Use

Have medications or supplements ever caused unusual side effects or problems? oYes oNoIf yes, describe: _____________________________________________________________________________

Have you used any of these regularly or for a long time:NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin? oYes oNo Tylenol (acetaminophen)? oYes oNoAcid-blocking drugs (Zantac, Prilosec, Nexium, etc.)? oYes oNo

How many times have you taken antibiotics?

< 5 > 5 Reason for Use

Infancy/Childhood

Teen

Adulthood

< 5 > 5 Reason for Use

Infancy/Childhood

Teen

Adulthood

Have you ever taken long term antibiotics? oYes oNoIf yes, explain: ______________________________________________________________________________

How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?


Readiness Assessment and Health Goals

Readiness Assessment

Rate on a scale of 5 (very willing) to 1 (not willing):

In order to improve your health, how willing are you to:Significantly modify your diet o 5 o4 o3 o2 o 1Take several nutritional supplements each day o5 o 4 o3 o2 o 1Keep a record of everything you eat each day o 5 o 4 o3 o2 o1Modify your lifestyle (e.g., work demands, sleep habits) o 5 o 4 o3 o2 o1Practice a relaxation technique o 5 o 4 o3 o2 o 1Engage in regular exercise o5 o4 o3 o2 o 1

Rate on a scale of 5 (very confident) to 1 (not confident at all):

How confident are you of your ability to organize and follow through on the above health-related activities? o 5 o 4 o3 o2 o 1

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through? _____________________________________

_________________________________________________________________________________________

Rate on a scale of 5 (very supportive) to 1 (very unsupportive):

At the present time, how supportive do you think the people in your household will be to your implementing the above changes? o5 o4 o3 o2 o1

Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):

How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program? o5 o4 o3 o2 o1

Comments ________________________________________________________________________________

_________________________________________________________________________________________


Health Goals

What do you hope to achieve in your visit with us? __________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

When was the last time you felt well? _____________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Did something trigger your change in health? ______________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What makes you feel better? ____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What makes you feel worse? ____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

How does your condition affect you? _____________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What do you think is happening and why? _________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What do you feel needs to happen for you to get better? ______________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Medical Symptoms Questionnaire (MSQ)

Patient Name _______________________________________________________________ Date ___________________

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale 0 – Never or almost never have the symptom1 – Occasionally have it, effect is not severe 2 – Occasionally have it, effect is severe

__________ Headaches __________ Faintness __________ Dizziness __________ Insomnia Total _________

__________ Watery or itchy eyes __________ Swollen, reddened or sticky eyelids __________ Bags or dark circles under eyes __________ Blurred or tunnel vision Total _________ (Does not include near or far-sightedness)

__________ Itchy ears __________ Earaches, ear infections __________ Drainage from ear __________ Ringing in ears, hearing loss Total _________

__________ Stuffy nose __________ Sinus problems __________ Hay fever __________ Sneezing attacks __________ Excessive mucus formation Total _________

__________ Chronic coughing __________ Gagging, frequent need to clear throat __________ Sore throat, hoarseness, loss of voice __________ Swollen or discolored tongue, gums, lips __________ Canker sores Total _________

__________ Acne __________ Hives, rashes, dry skin __________ Hair loss __________ Flushing, hot flashes __________ Excessive sweating Total _________

__________ Irregular or skipped heartbeat __________ Rapid or pounding heartbeat __________ Chest pain Total _________

3 – Frequently have it, effect is not severe 4 – Frequently have it, effect is severe

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

HEAD

Version 2

MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)

__________ Chest congestion __________ Asthma, bronchitis __________ Shortness of breath __________ Difficulty breathing Total _________

__________ Nausea, vomiting __________ Diarrhea __________ Constipation __________ Bloated feeling__________ Belching, passing gas __________ Heartburn __________ Intestinal/stomach pain Total _________

__________ Pain or aches in joints __________ Arthritis __________ Stiffness or limitation of movement __________ Pain or aches in muscles __________ Feeling of weakness or tiredness Total _________

__________ Binge eating/drinking __________ Craving certain foods __________ Excessive weight __________ Compulsive eating __________ Water retention __________ Underweight Total _________

__________ Fatigue, sluggishness __________ Apathy, lethargy __________ Hyperactivity __________ Restlessness Total _________

__________ Poor memory __________ Confusion, poor comprehension __________ Poor concentration __________ Poor physical coordination __________ Difficulty in making decisions __________ Stuttering or stammering __________ Slurred speech __________ Learning disabilities Total _________

__________ Mood swings __________ Anxiety, fear, nervousness __________ Anger, irritability, aggressiveness __________ Depression Total _________

__________ Frequent illness __________ Frequent or urgent urination __________ Genital itch or discharge Total _________

Grand Total _________

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

LUNGS

Taking an Exposure History

Exposure History FormPart 1. Exposure Survey Name: Date:Please circle the appropriate answer. Birth date: Sex (circle one): Male Female

1. Are you currently exposed to any of the following?metals no yesdust or fibers no yeschemicals no yesfumes no yesradiation no yesbiologic agents no yesloud noise, vibration, extreme heat or cold no yes

2. Have you been exposed to any of the above in the past? no yes

3. Do any household members have contact with metals,dust, fibers, chemicals, fumes, radiation, or biologic agents? no yes

If you answered yes to any of the items above, describe your exposure in detail—how you were exposed,to what you were exposed. If you need more space, please use a separate sheet of paper.

4. Do you know the names of the metals, dusts, fibers,chemicals, fumes, or radiation that you are/wereexposed to? no yes

5. Do you get the material on your skin or clothing? no yes

6. Are your work clothes laundered at home? no yes

7. Do you shower at work? no yes

8. Can you smell the chemical or material you areworking with? no yes

9. Do you use protective equipment such as gloves,masks, respirator, or hearing protectors? no yes

10. Have you been advised to use protective equipment? no yes

11. Have you been instructed in the use of protectiveequipment? no yes

If yes, list them below

If yes, list the protectiveequipment used

Developed by ATSDR in cooperation with NIOSH, 1992


12. Do you wash your hands with solvents? no yes

13. Do you smoke at the workplace? no yes At home? no yes

14. Are you exposed to secondhand tobacco smoke at the workplace? no yes At home? no yes

15. Do you eat at the workplace? no yes

16. Do you know of any co-workers experiencing similar or unusual symptoms? no yes

17. Are family members experiencing similar or unusual symptoms? no yes

18. Has there been a change in the health or behavior of family pets? no yes

19. Do your symptoms seem to be aggravated by a specific activity? no yes

20. Do your symptoms get either worse or better at work? no yes at home? no yes on weekends? no yes on vacation? no yes

21. Has anything about your job changed in recent months (such as duties, procedures, overtime)? no yes

22. Do you use any traditional or alternative medicines? no yes

If you answered yes to any of the questions, please explain.

Page 2


The following questions refer to your current or most recent job:

Job title: Describe this job:

Type of industry:

Name of employer:

Date job began:

Are you still working in this job? yes no

If no, when did this job end?

Part 2. Work History Name: ______________________________A. Occupational Profile Birth date: __________________ Sex: Male Female

Fill in the table below listing all jobs you have worked including short-term, seasonal, part-time employment, andmilitary service. Begin with your most recent job. Use additional paper if necessary.

*List the chemicals, dusts, fibers, fumes, radiation, biologic agents (i.e., molds or viruses) and physical agents (i.e., extreme heat, cold, vibration, or noise) that you were exposed to at this job.

Have you ever worked at a job or hobby in which you came in contact with any of the following by breathing,touching, or ingesting (swallowing)? If yes, please check the box beside the name.

Developed by ATSDR in cooperation with NIOSH, 1992

Dates of Employment Job Title and Description of Work Exposures* Protective Equipment

AcidsAlcohols (industrial)AlkaliesAmmoniaArsenicAsbestosBenzeneBerylliumCadmiumCarbon tetrachlorideChlorinated naphthalenesChloroform

ChloropreneChromatesCoal dustDichlorobenzeneEthylene dibromideEthylene dichlorideFiberglassHalothaneIsocyanatesKetonesLeadMercury

Methylene chlorideNickelPBBsPCBsPerchloroethylenePesticidesPhenolPhosgeneRadiationRock dustSilica powderSolvents

StyreneTalcTolueneTDI or MDITrichloroethyleneTrinitrotolueneVinyl chlorideWelding fumesX-raysOther (specify)

Page 3


B. Occupational Exposure Inventory Please circle the appropriate answer.

Part 3. Environmental History Please circle the appropriate answer.

1. Have you ever been off work for more than 1 day because of an illness related to work? no yes

2. Have you ever been advised to change jobs or work assignments because of any healthproblems or injuries? no yes

3. Has your work routine changed recently? no yes

4. Is there poor ventilation in your workplace? no yes

1. Do you live next to or near an industrial plant, commercial business, dump site, or nonresidential property? no yes

2. Which of the following do you have in your home? Please circle those that apply. Air conditioner Air purifier Central heating (gas or oil?) Gas stove Electric stove Fireplace Wood stove Humidifier

3. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home? no yes

4. Have you weatherized your home recently? no yes

5. Are pesticides or herbicides (bug or weed killers; flea and tick sprays, collars, powders, or shampoos) used in your home or garden, or on pets? no yes

6. Do you (or any household member) have a hobby or craft? no yes

7. Do you work on your car? no yes

8. Have you ever changed your residence because of a health problem? no yes

9. Does your drinking water come from a private well, city water supply, or grocery store?

10. Approximately what year was your home built?_______________

If you answered yes to any of the questions, please explain.

Page 4

This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use.

ENVIRONMENTAL SENSITIVITY QUESTIONNAIRE

1. Do you have or use any of the following at/near home or work?

Exposure: Home Work Exposure Home Work a. Spring water u. Foam rubber pillows b. Well water v. Feather/down

Comforter

c. Water purifier w. Coat/jacket d. Damp cellar x. Stuffed upholstery e. Wooded area y. Animals f. Swamp z. Polyester blend in:

Sheets

g. Power lines aa. Pillow case h. Microwave transmitter ab. Pajamas i. Smoke stacks ac. Shirts j. Dump ad. Skirts k. Gas stove ae. Pants l. Gas furnace af. Exterminator m. Gas hot water heater ag. Moth balls n. Gas dryer ah. Mold on:

Shower curtain

o. Wood stove ai. Basement walls p. Coal stove aj. First story walls q. Kerosene space heater ak. Second story walls r. Forced hot air heat al. Garage under living space s. Electric blankets am. Urea formaldehyde

insulation

t. Feather pillows an. Other:

PLEASE TURN PAGE OVER AND COMPLETE THE OTHER SIDE.

This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use.

2. Are you bothered by: (check appropriate selections)

a. Gasoline fumes l. Fabric stores b. Diesel exhaust m. New car smell c. Soaps n. Air conditioners d. Detergents o. Newsprint e. Chlorinated water p. Tobacco smoke f. Moth balls q. Cats g. Asphalt/tar r. Dogs h. Hair spray s. Mold i. Cosmetics t. Tree pollen j. Perfume u. Grass pollen k. Dust v. Ragweed pollen

3. Please check appropriate selections about carpeting in your home.

BEDROOM � LIVING ROOM � FAMILY ROOM � a. None h. None r. None b. Area rugs i. Area rugs s. Area rugs c. Wall to wall j. Wall to wall t. Wall to wall d. Wool k. Wool u. Wool e. Synthetic pad l. Synthetic pad v. Synthetic pad f. Glued down m. Glued down w. Glued down g. How old is carpeting? n. How old is carpeting? x. How old is carpeting? o. On slab y. On slab p. Ever damp? z. Ever damp? q. Moldy aa. Moldy

Daily Activity Questionnaire


Please check the one best response for each activity described below:

o 1 Most of the day o 2 Half of the day o 3 Some of the day o 4 Rarely Total _________

o 1 Need some assistance o 2 Slight difficulty o 3 Minimal difficulty o 4 No problem Total _________

o 1 Unable o 2 Occasionally o 3 Regularly in small steps or with help o 4 Regularly without help Total _________

o 1 Unable o 2 Take-out, breakfast, or simple lunch only o 3 Simple microwave or crockpot meal o 4 Regular meals Total _________

o 1 Unable o 2 Light dusting, straighten up o 3 Regular housekeeping in small steps or with help o 4 Fully capable Total _________

o 1 Unable o 2 Occasional (once or twice per month) o 3 Frequent, but with assistance o 4 No problem Total _________

o 1 Unable o 2 Infrequently o 3 Occasionally (once or twice per month) o 4 Frequently (weekly or more often) Total _________

o 1 Unable o 2 Very limited o 3 Cautious, local trips o 4 Distant trips or traffic Total _________

o 1 None o 2 0-1 per day o 3 2-3 per day o 4 No or few restrictions Total _________

Grand Total _________

ACTIVITIES OF DAILY LIVING

SEDENTARY BEHAVIOR

LAUNDRY

COOKING

HOUSEKEEPING

GROCERY SHOPPING

SOCIAL ACTIVITIES

DRIVING

ERRANDS OR LIGHT CHORES


Bathing, dressing, feeding self, toilet

Sitting while watching TV, at a computer, driving, talking on the phone, or reading

Church, temple, family and friends

Post office, drop off a child


1. Have you been cleared for exercise? oYes oNo

2. What are you doing on a regular basis that gets you moving and gets your heart rate up? Cardio/Aerobic exercise: (e.g., walking, jogging, running, dancing) Activity 1 ___________________________________________________ ______ x per week for _______ minutes Activity 2 ___________________________________________________ ______ x per week for _______ minutes

Strength/Resistance exercise: (e.g., resistance machines, kettle bell, pilates, weightlifting) Activity 1 ___________________________________________________ ______ x per week for _______ minutes Activity 2 ___________________________________________________ ______ x per week for _______ minutes

Flexibility/Stretching exercise: (e.g., yoga, pilates, matwork, stretches) Activity 1 ___________________________________________________ ______ x per week for _______ minutes Activity 2 ___________________________________________________ ______ x per week for _______ minutes

Balance exercise: (e.g., tai chi, qi gong, bosu ball, dancing) Activity 1 ___________________________________________________ ______ x per week for _______ minutes Activity 2 ___________________________________________________ ______ x per week for _______ minutes

3. How do you monitor your exercise intensity?

Exercise History Questionnaire


o General Intensity o Talk Test o Perceived Exertion o Heart Rate*

Light Able to talk and/or sing < 3 (10 point scale) < 64% HRmax

Moderate Able to talk but not sing 3–4 (10 point scale) 64–76% HRmax

Vigorous/hard Difficulty talking ≥ 5 (10 point scale) >76% HRmax

4. Are you satisfied with your current exercise program? oYes oNo If no, explain ____________________________________________________________________________________

5. What are your motivators for exercise? (Check all that apply)

oPrevent cardiac disease and strokeoReduce blood pressureoControl blood glucoseoPrevent bone lossoIncrease energyoIncrease self esteemoImprove mood

*Not an appropriate measure of intensity if taking a Beta Blocker

oDecrease stressoImprove sleepoWeight reductionoIncrease mental alertnessoBetter enduranceoIncrease interest in sexoOther ___________________________________________________

6. What types of aerobic exercise do you prefer? (Circle all that apply)Walking, hiking, blading, jogging, treadmill, bicycling indoors/outdoors, EFX elliptical, stair climbers, swimming, rowing, water aerobics, aerobics classes, cross country skiing, downhill skiing/snowboarding, snowshoeing, other _____________

7. What do you like most about exercising? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

8. Do you have an exercise partner? oYes oNo9. Do you enjoy group exercise or classes? oYes oNo10. Are you a member of a gym or fitness center? oYes oNo11. Are there any obstacles you have to engaging in movement and physical activity? oYes oNo

a. If yes, what are they? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

b. If yes, do you have control over the circumstances surrounding your obstacles? How can you overcome them? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

c. Are any of your obstacles out of your control? If yes, which ones? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

d. What are some possible solutions around these obstacles? What has worked before? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

12. What is the best time of day for you to exercise? ______________________________________________________13. When do you have the most energy and time? _______________________________________________________14. Are you ready to take action to make your exercise program work for you and your goals? oYes oNo15. Do you have any goals related to you strength, tone, body composition, or fitness level? oYes oNo

If yes, explain: ___________________________________________________________________________________16. Do you experience any pain or breathing problems while exercising? oYes oNo

If yes, explain: ___________________________________________________________________________________17. Do you have any joint or musculoskeletal problems that might flare up during exercise? oYes oNo

If yes, explain: ___________________________________________________________________________________18. Have you had any injuries while exercising? oYes oNo

If yes, explain: ___________________________________________________________________________________19. Have you experienced a loss of muscle tissue or a decline in strength over the last few years? oYes oNo 20. Have you fallen in the past few months? oYes oNo 21. Do you notice any balance problems? oYes oNo

If yes, explain: ___________________________________________________________________________________22. Do you have any of the following exercise contraindications? (Check all that apply)oAcute systemic infection (i.e., fever, body aches, swollen lymph nodes, etc.)oArrhythmiasoRecent heart attackoSevere congestive heart failureoUncontrolled angina/chest painoOther _______________________________________________________________________________________

EXERCISE HISTORY QUESTIONNAIRE

© 2015 The Institute for Functional Medicine

How Healthy Is Your Diet?

Circle your answers after careful thought, then add up your points (numbers in parentheses).

1. How many fruits do you normally eat each day (1/2 cup fresh or dried fruit, 1 medium piece, 1 cup unsweetened juice)? A. 0 (-2) B. 1 (0) C. 2 to 3 (+2) D. 4 or more (+3) (score) _____

2. How many vegetable servings do you normally eat each day (1 cup leafy greens, 1/2 cup any other veggie, raw or cooked)? A. 0 (-4) B. 1 (0) C. 2 (+1) D. 3 (+2) E. 4 or more (+3) (score) _____

3. How many different varieties of vegetables do you eat in a normal month? A. 2 or less (-4) B. 3 to 4 (0) C. 5 to 6 (+1) D. 7 to 8 (+3) E. 9 or more (+4) (score) _____

4. How many times do you eat dried beans or peas (legumes, lentils, chickpeas, kidney beans, green peas, etc.) in a normal week? A. 0 (-2) B. 1 to 2 (0) C. 3 to 4 (+1) D. 5 to 6 (+2) E. 7 or more (+3) (score) _____

5. How many times do you eat red meat in a normal week? A. 6 or more (-4) B. 4 to 5 (-3) C. 1 to 3 (-1) D. Less than once a week (+2) E. 0 (+3) (score) _____

6. How many times do you eat in a fast food restaurant in a normal week? A. 6 or more (-5) B. 4 to 5 (-4) C. 1 to 3 (-3) D. Less than once a week (-2) E. 0 (0) (score) _____

7. In a typical day, what do you drink most often? A. Soda (regular or diet) (-4) B. Caffeinated coffee or tea (-1) C. Decaffeinated coffee or tea (0) D. Milk or fruit juice (0) E. Herbal tea or water (+3) (score) _____

8. How many 12 oz. cans of soda do you drink in a normal day? A. 6 or more (-5) B. 4 to 5 (-4) C. 2 to 3 (-3) D. 1 (-2) E. Less than 1 (-1) F. 0 (0) (score) _____

9. How often do you eat fish in a typical week? A. Never (-2) B. Once (+1) C. Twice (+2) D. 3 to 5 times (+3) (score) _____

10. In a typical week, how often do you eat whole grains (100% whole grain bread, whole oats, brown rice, quinoa, whole rye crackers)? A. Never (-3) B. 1 to 2 times a week (-1) C. 3 to 4 times a week (0) D. 5 to 6 times a week (+1) E. 1 or more times a day (+3) (score) _____

11. How often do you eat sweets such as cookies, cakes, or ice cream? A. 1 or more times a day (-3) B. Every other day (-2) C. Twice a week (-1) D. Once a week (0) E. 2 to 3 times a month (+1) F. Rarely (+3) (score) _____

Your Total Score__________________

Scoring: 22–28 – Great eating habits 17–21 – Pretty good eating habits 10–16 – Needs some improvement 9 or less – Needs much improvement; try to change one habit at a time



Sleep is important for musculoskeletal healing and for healthy immune function, mood, cognitive and brain function,

and for many physiological functions.

Please answer the following questions as accurately and fully as possible. For Yes / No questions, please check the correct

answer and provide an explanation if one is requested. The information will help to determine whether you are getting the

sleep you need and to identify possible strategies to help you sleep better.

Sleep Problems:

1 Do you have a sleep problem that has been diagnosed? oYes oNo If yes, what? ___________________________________________________________________________________

2 Do you feel that you have a sleep problem? oYes oNo If yes, how would you describe it? _________________________________________________________________

Sleepiness Questions:

3 Do you feel well rested in the morning? oYes oNo Please explain _________________________________________________________________________________

4 Are there times during the day or evening that you feel sleepy? oYes oNo If yes, what times are these? _______________________________________________________________________

5 What do you do to wake up when you feel sleepy? ____________________________________________________

6 Have you ever had an accident at work, at home or on your job because you were sleepy? oYes oNo If yes, please explain ____________________________________________________________________________

7 Do you take naps? oYes oNo If yes, for how many minutes and at what time of day? _________________________________________________

8 Do you feel well rested after a nap? oYes oNo

Insomnia Questions:

9 Can you usually fall asleep within 20 minutes of lying in bed? oYes oNo

10 How long does it usually take you to fall asleep? ______________________________________________________

11 Do you ever feel so wired at night that it is difficult to fall asleep? oYes oNo

12 Have you had a saliva cortisol test? oYes oNo If yes, what was your night time level? ______________________________________________________________

Sleep Questionnaire

Version 2


Insomnia Questions:

13 Do you currently take, or have you tried, any of the following sleep aids to fall asleep? oYes oNo If yes, how many times per week do you take them? Please answer with an E for effective or an N for not effective in helping you to sleep:

Sleep Aids Tried in the past? Taking now? Dosage? E or N?

Ambien (zolpidem)

Sonata (zaleplon)

Valium (diazepam)

Ativan (lorazepam)

Restoril (temazepam)

Tylenol PM

Benadryl

Calcium/Magnesium

Valerian

Kava

Melatonin

L-Tryptophan

Other? (Please specify)

_______________________

14 Do you wake up in the middle of the night? oYes oNo If yes, how many times times and for what reasons? ____________________________________________________

15 Do you have any trouble falling back asleep when you wake up? oYes oNo If yes, how long does it usually take you? ____________________________________________________________

16 Does feeling the need to move your feet or legs at night keep you awake or have you been diagnosed with Restless Legs Syndrome? oYes oNo

17 Do you have disturbing dreams at night? oYes oNo


Caffeine and Other Stimulants:

18 If you drink or eat any of the following, please indicate how much (number of ounces, cups, glasses, etc.), how often per day, and at what times per day?

Stress and Stress Reduction:

20 What kind of stress have you been under in the past few months? _________________________________________

21 What do you do for stress management? ____________________________________________________________

22 Do you have a journal to write in that is near your bed? oYes oNo

23 Do you exercise aerobically? oYes oNo If yes, what do you do, how often do you exercise, and at what time of day? _________________________________ _____________________________________________________________________________________________

Sleep Hygiene:

24 What time do you usually go to bed? _______________________________________________________________

25 What time do you usually wake up? ________________________________________________________________

26 Do you feel that you go to bed too late? oYes oNo If yes, what time would you like to go to bed? ________________________________________________________

27 Do you watch TV in the evenings oYes oNo If yes, what hours do you watch it? _________________________________________________________________

28 Is the TV in your bedroom or in a family room? ______________________________________________________

29 On the weekend or days off do you vary your sleep schedule? oYes oNo

30 How many hours are you physically in your bed? _____________________________________________________

Do you use… How much? How often per day? When during the day?

Coffee

Caffeinated sodas (Coke, Pepsi, Mountain Dew, etc.)

Caffeinated water

Green tea

Black tea

Other tea

Chocolate

Coffee or espresso ice creams

Sudafed or other OTC cold medications

Alcohol

19 What medications are you on and what time do you take them? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Sleep Hygiene:

31 How many hours of the time spent in bed are you actually asleep? ________________________________________

32 Do you have much light coming into your bedroom? oYes oNo

33 What can you see at night without any lights on? _____________________________________________________

34 Do you have little children who wake you up? oYes oNo

Bedroom, Breathing and Environment:

35 Is the air in your bedroom clean or dirty?____________________________________________________________

36 Are there any unusual smells in your bedroom? oYes oNo If yes, please describe ____________________________________________________________________________

37 Do you snore, stop breathing, or have trouble breathing at night? oYes oNo

38 Do you use Breathe-Easy strips on your nose? oYes oNo If yes, do they help you to breath? oYes oNo

39 Do you have carpets or hardwood floors in your bed room? _____________________________________________

40 How many rooms in your home have carpets and how old are the carpets? _________________________________

41 What type of heat is in your home: forced air or radiant? _______________________________________________

42 How often do you change the furnace filter in your home?______________________________________________

43 Have you seen any black mold in your window sills or in a basement? oYes oNo

44 Do you have a HEPA air filter for your bedroom? oYes oNo If yes, what brand is it and how long do you run it each day? ____________________________________________

45 What type of vacuum cleaner do you use and does it have a HEPA filter in it? _______________________________

46 How often do you clean the dust in your bedroom? ___________________________________________________

47 Do you sleep with an animal that snores or moves around and disturbs you? oYes oNo

48 Do you sleep with a bed partner who snores, moves around at night or disturbs you when you are trying to sleep? oYes oNo

49 Do noises wake you up? oYes oNo If yes, what are they? ____________________________________________________________________________

50 Do you live on a noisy street? oYes oNo

51 Do you feel safe in your bed at night? oYes oNo If not, explain _________________________________________________________________________________

Bed, Pillows, and Pain:

52 What type of bed do you have and what size is it? _____________________________________________________

53 Do you wake up because of pain? oYes oNo If yes, at what time and where is the pain? ___________________________________________________________

54 What type of pillow is most comfortable for you and what type have you tried that did not work? ____________________________________________________________________________________________

55 Do you use body pillows? oYes oNo If yes, how many and how do you use them? _________________________________________________________


Depression Anxiety Stress Scales

SYMPTOMS

1 I found myself getting upset by quite trivial things 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn’t seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion) 0 1 2 3

5 I just couldn’t seem to get going 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I had a feeling of shakiness (e.g., legs going to give way) 0 1 2 3

8 I found it difficult to relax 0 1 2 3

9 I found myself in situations that made me so anxious I was most relieved when they ended 0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting upset rather easily 0 1 2 3

12 I felt that I was using a lot of nervous energy 0 1 2 3

13 I felt sad and depressed 0 1 2 3

14 I found myself getting impatient when I was delayed in any way (e.g., elevators, traffic lights, being kept waiting) 0 1 2 3

15 I had a feeling of faintness 0 1 2 3

16 I felt that I had lost interest in just about everything 0 1 2 3

17 I felt I wasn’t worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I perspired noticeably (e.g., hands sweaty) in the absence of high temperatures or physical exertion 0 1 2 3

20 I felt scared without any good reason 0 1 2 3

21 I felt that life wasn’t worthwhile 0 1 2 3

Rating Scale

From: Lovibond, SH and Lovibond PF. (1995) Manual for the Depression Anxiety Stress Scales (2nd Ed.). Sydney: Psychology Foundation


Please read each statement and circle a number 0, 1, 2 or 3 that indicates how much the statement applied to you

over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 – Did not apply to me at all1 – Applied to me to some degree, or some of the time

2 – Applied to me to a considerable degree, or a good part of time3 – Applied to me very much, or most of the time

Please turn the page

From: Lovibond, SH and Lovibond PF. (1995) Manual for the Depression Anxiety Stress Scales (2nd Ed.). Sydney: Psychology Foundation

SYMPTOMS (continued)

22 I found it hard to wind down 0 1 2 3

23 I had difficulty in swallowing 0 1 2 3

24 I couldn’t seem to get any enjoyment out of the things I did 0 1 2 3

25 I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat) 0 1 2 3

26 I felt down-hearted and blue 0 1 2 3

27 I found that I was very irritable 0 1 2 3

28 I felt I was close to panic 0 1 2 3

29 I found it hard to calm down after something upset me 0 1 2 3

30 I feared that I would be “thrown” by some trivial but unfamiliar task 0 1 2 3

31 I was unable to become enthusiastic about anything 0 1 2 3

32 I found it difficult to tolerate interruptions to what I was doing 0 1 2 3

33 I was in a state of nervous tension 0 1 2 3

34 I felt I was pretty worthless 0 1 2 3

35 I was intolerant of anything that kept me from getting on with what I was doing 0 1 2 3

36 I felt terrified 0 1 2 3

37 I could see nothing in the future to be hopeful about 0 1 2 3

38 I felt that life was meaningless 0 1 2 3

39 I found myself getting agitated 0 1 2 3

40 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3

41 I experienced trembling (e.g., in the hands) 0 1 2 3

42 I found it difficult to work up the initiative to do things 0 1 2 3

Rating Scale

The rating scale is as follows:

0 – Did not apply to me at all1 – Applied to me to some degree, or some of the time

2 – Applied to me to a considerable degree, or a good part of time3 – Applied to me very much, or most of the time

General Office Policies Please review carefully. Sign and date.

• Patient Responsibility: You are encouraged to ask questions on any health-related topic and to take an active role in your health-care.

• Confidentiality: Information revealed during office visits is confidential. Your record and the information contained within it will not be disclosed to others unless you direct us to do so in writing. Exceptions to this confidentiality include disclosure of the intent to harm yourself or others and subpoena from specific government agencies (as outlined in the HIPAA Privacy Rule).

• Treatment Plan: Each treatment plan and/or procedure possesses both risks and benefits. You are encouraged to ask questions if you would like additional information. Although your plan will be thoroughly researched and customized to your individual personal goals and health status, no guarantees can be assured regarding the outcomes of treatment plan(s) or procedure(s).

• Office Visits: Effective April 1st, 2018: office visits are billed at $250.00 per hour. The first office visit is $500.00 and is typically 2 hours long. This length may vary. If a longer visit is necessary, you will notified of this prior to your appointment. Subsequent follow-up visits are a minimum of 30 minutes. There is no refund for services provided. You may be eligible for out-of-network insurance reimbursement or tax deduction for medical services.

• Insurance: We do not accept any insurance. All fees are settled directly between patient and provider. At the patient’s request, we will provide you with the necessary forms and diagnostic codes needed for you to submit an out-of-network claim to your insurance. Please note that we are are not Medicare providers and are opted out of the Medicare program. Our services can not be submitted to Medicare for reimbursement.

• Payment: We accept cash, money orders and most major credit cards. Checks are not accepted.

• Cancellation policy: When an appointment is scheduled, time is reserved especially for you and no one else. Since our appointments are much longer than standard office visits, cancellations are significant interruptions to the Clinic. Thus, a minimum of 3 days’ notice is required for cancellations of new patient visits and 1 day notice for existing patients. There will be a 100% office visit charge for “no-shows” or late cancellations.

• Specialty Laboratory Testing: Our clinic frequently uses specialty testing. These are usually an out-of-pocket expense. Occasionally, there is some insurance coverage. We will guide you through identifying the costs associated with your testing.

• Treatment Plan Questions: We encourage patients to call or e-mail with questions regarding their treatment plan. If there is a need for longer discussion regarding new symptoms or new concerns, then we recommend you schedule an additional follow-up appointment. Questions that require longer than 5-minute responses fit this scenario. Additionally, if it has been longer than 8 weeks since your last appointment, schedule an appointment rather than email.

• Emergencies and after-hours care: The Clinic is not a primary care clinic - we offer consultative services only. You must have a primary care doctor with whom you can consult in the event of an emergency or urgent problem. If you notice an adverse effect from one of the components of your Clinic treatment plan, you should discontinue it then email or call the Clinic during normal business hours. If you have a serious health problem that requires immediate attention, you should call your other doctors(s), call 911, or have someone take you to the nearest hospital emergency room.

• Please email us at [email protected] for any questions regarding this policy.

I agree to all terms and conditions of these General Office Policies.

Signature: Date: ____________________________________________________________________

I agree to allow Armen E. Nikogosian, MD to use or to describe my anonymous medical history and laboratory data for educational purposes in lectures, blogs, case reports, and other publications that are communicated to other professionals, but may include members of the public. This medical history and laboratory data might include photographs and/or other images of parts of my body other than my face (nutrition/physical exam findings only). Armen E. Nikogosian, MD will never publish any information that uses my name or that identifies me as the source of any of the information, data, or images that it publishes. If you do not wish to participate, initial here:______

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Male Intake Questionnaire - …southwestfunctionalmedicine.com/wp-content/uploads/2018/03/... · Male Intake Questionnaire ... o Chocolate o Alcohol o Red wine o Sul!te–containing