Current health problem
What is your priority of concerns?
Drugs / Supplements
Do you take any drugs?
Do you take any supplements?
What is your reactions to food?
Smoking / Drinking
Do you smoke? (Number of cigarettes smoked per week)
Do you drink? (Alcohol consumption levels and patterns)
Have you experienced Major stress recently?
Are you a type of Anxious or easy going / relax person?
Do you always feel fatigue, tired, lethargy, or foggy memmory?
How much time have you lost from work or school in the past year?
Past Medical and Surgical History:
Hospitalization (WHERE HOSPITALIZED / WHEN / FOR WHAT REASON)
How often have you have taken antibiotics?
How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
As a child, were there any foods that you had to avoid because they gave you symptoms?
Please describe your current diet and provide your 24 hour diet recall, if possible an average of the three day dietary pattern is the prefer option.
How much of the following do you consume each week?
Do you have symtoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?
Do you feel you have delayed symtoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?
Do you feel much worse when you eat a lot of :
Do you feel much better when you eat a lot of :
Does skipping a meal greatly affect your symptoms?
Have you ever had a food that you craved or really "binged" on over a period of time?
Please fill in the chart below with information about your bowel movements
How do you feel after finishing your exercise?
How is your body weight in the past three years?
Do you have mercury amalgam fillings?
Do you have any artificial joints or implants?
Do you feel worse at certain times of the year?
Have you, to your knowledge, been exposed to toxic metals in your job or at home?
Do you have any reaction to chemicals, odors, perfumes or smoke / cigarette?
Have you ever had psychotherapy or counseling?
For women only.
1. How is your period?
2. Do you have premenstrual symptoms?
3. Do you have any breast cysts / lumps?
4. Do you have Ovarian cyst, Endometriosis?
5. Do you have Vaginal discharge?